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10139992-DS-23 | 10,139,992 | 22,906,379 | DS | 23 | 2123-09-29 00:00:00 | 2123-09-29 15:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Upper respiratory tract infection symptoms
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with a history of EtOH cirrhosis and
hepatopulmonary syndrome who underwent living donor liver
transplant 6 weeks ago. He has had a persistent O2 requirement
of
___ L since discharge after transplant and has been followed by
pulmonology. CT scan yesterday showed ground glass
opacifications
in bilateral upper lobes. Seen in transplant clinic with Dr.
___ who recommended going to ED given concern for
respiratory infection. Reports SOB on home ___, hypoxia on
mild exertion, subjective fever, nonproductive cough, nausea.
Denies chest pain, vomiting. Currently afebrile with central
cyanosis on 6L, on fluc/valgan/bactrim, MMF/pred/tacro
post-transplant. Positive for Flu A.
Past Medical History:
- ethanol-induced liver cirrhosis, hx alcoholic hepatitis
- ___ living donor liver transplant
- portal hypertension
- esophageal varices s/p banding
- hepatopulmonary syndrome
- thrombocytopenia
- arterial hypertension
- insulin dependent type 2 diabetes mellitus
- obstructive sleep apnea
- depression
- anxiety
- prolonged QT interval
- hypokalemia
Social History:
___
Family History:
___ is one of 18 children. One sibling died from
complications associated with ETOH abuse. One sister has a
seizure disorder. Another sister died aged ___ from glioblastoma.
One brother died aged ___ from lung cancer. His father has
diabetes.
Multiple family members with IBD.
Physical Exam:
ADMISSION EXAM:
===============
VS: T 98.2 BP 103/75 HR 91 RR 24 SO2 91% RA on 6L
Neuro: A/o x3. PERRLA.
CV: Regular rate and rhythm. No heart murmurs. No rubs/gallops.
Resp: CTAB, central cyanosis, mildly increased WOB
___: BS present. Soft, non-tender, no rebound/guarding.
Extremities: Warm. Radialis and dorsalis pedis pulses palpable.
No peripheral edema. Marked clubbing of fingernails
DISCHARGE EXAM:
===============
VS: T 98.3 BP 131/73 HR 81 RR 18 SO2 94% on 6L
Gen: NAD, comfortable, alert
Neuro: A&Ox3
CV: RRR No M/R/G
Resp: CTAB, non-labored breathing on 6LNC
GI: Soft, NT, ND
Extremities: WWP, no edema, clubbing of fingernails
Pertinent Results:
LABS:
=====
___ 09:22AM BLOOD WBC-8.7 RBC-5.37 Hgb-18.4* Hct-53.2*
MCV-99* MCH-34.3* MCHC-34.6 RDW-13.9 RDWSD-50.8* Plt ___
___ 04:51AM BLOOD WBC-7.9 RBC-4.86 Hgb-16.6 Hct-46.8 MCV-96
MCH-34.2* MCHC-35.5 RDW-13.5 RDWSD-48.2* Plt Ct-98*
___ 04:52AM BLOOD WBC-5.9 RBC-5.03 Hgb-17.2 Hct-48.6 MCV-97
MCH-34.2* MCHC-35.4 RDW-13.5 RDWSD-48.4* Plt ___
___ 06:15AM BLOOD WBC-6.7 RBC-5.16 Hgb-17.5 Hct-50.0 MCV-97
MCH-33.9* MCHC-35.0 RDW-13.4 RDWSD-48.2* Plt ___
___ 02:00PM BLOOD ___ PTT-27.5 ___
___ 04:51AM BLOOD ___ PTT-25.3 ___
___ 04:51AM BLOOD ___ 09:22AM BLOOD UreaN-22* Creat-1.0 Na-140 K-4.2 Cl-97
HCO3-24 AnGap-19*
___ 09:22AM BLOOD Glucose-221*
___ 04:51AM BLOOD Glucose-98 UreaN-15 Creat-0.8 Na-142
K-3.9 Cl-103 HCO3-23 AnGap-16
___ 04:52AM BLOOD Glucose-116* UreaN-19 Creat-0.9 Na-142
K-4.2 Cl-103 HCO3-23 AnGap-16
___ 06:15AM BLOOD Glucose-95 UreaN-20 Creat-0.9 Na-144
K-4.2 Cl-103 HCO3-26 AnGap-15
___ 09:22AM BLOOD ALT-54* AST-34 AlkPhos-121 TotBili-1.3
___ 04:51AM BLOOD ALT-46* AST-31 AlkPhos-104 TotBili-0.9
___ 04:52AM BLOOD ALT-47* AST-32 AlkPhos-112 TotBili-0.8
___ 06:15AM BLOOD ALT-47* AST-31 AlkPhos-114 TotBili-0.9
___ 09:22AM BLOOD Albumin-4.3 Calcium-9.8 Phos-3.5 Mg-1.7
___ 04:51AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.6
___ 04:52AM BLOOD Calcium-9.0 Phos-5.2* Mg-1.8
___ 06:15AM BLOOD Calcium-9.3 Phos-4.6* Mg-1.5*
___ 09:22AM BLOOD tacroFK-9.4
___ 04:51AM BLOOD tacroFK-10.1
___ 04:52AM BLOOD tacroFK-10.0
___ 12:05PM OTHER BODY FLUID FluAPCR-POSITIVE*
FluBPCR-NEGATIVE
IMAGING/STUDIES:
================
CXR ___:
FINDINGS:
The lungs are well inflated and clear without consolidation,
effusion, or
edema. The cardiomediastinal silhouette is within normal
limits. No acute
osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Brief Hospital Course:
Mr. ___ is a ___ y/o male with history of liver disease
complicated by hepatopulmonary syndrome s/p a living donor liver
transplant on ___ who presents with influenza - like illness
and tested positive for Influenza A. The patient was admitted to
the hospital for close monitoring given his recent liver
transplant, immunosuppression and hepatopulmonary syndrome which
is not yet resolved post transplant, still having an O2
requirement at baseline. ID was consulted and recommended that
he be started on Tamiflu for which he received on admission and
for a minimum 5-day course with possible extension pending
evaluation in outpatient follow up. He worked with ___ to assess
ambulation/desaturation levels which are back to baseline
functioning. His immunosuppression regiment was continued during
this visit. By discharge, he was at baseline oxygen requirement
with no evident flu symptoms.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Famotidine 20 mg PO BID
3. Fluconazole 400 mg PO Q24H
4. FLUoxetine 10 mg PO DAILY
5. Glargine 18 Units Breakfast
Glargine 16 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
6. Mycophenolate Mofetil 1000 mg PO BID
7. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
8. PredniSONE 7.5 mg PO DAILY
9. Sodium Polystyrene Sulfonate 15 gm PO ASDIR hyperkalemia
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
11. Tacrolimus 1 mg PO Q12H
12. Ursodiol 300 mg PO BID
13. ValGANCIclovir 900 mg PO Q24H
14. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
15. Magnesium Oxide 400 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. OSELTAMivir 75 mg PO BID
RX *oseltamivir 75 mg 1 capsule(s) by mouth Twice a day Disp #*5
Capsule Refills:*1
2. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
Maximum 4 of the 500 mg tablets daily
3. Atorvastatin 10 mg PO QPM
4. Famotidine 20 mg PO BID
5. Fluconazole 400 mg PO Q24H
End date ___
6. FLUoxetine 10 mg PO DAILY
7. Glargine 18 Units Breakfast
Glargine 16 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
8. Magnesium Oxide 400 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Mycophenolate Mofetil 1000 mg PO BID
11. PredniSONE 7.5 mg PO DAILY
Follow transplant clinic taper
5 mg starting ___
12. Sodium Polystyrene Sulfonate 15 gm PO ASDIR hyperkalemia
Take only as directed by the transplant clinic
13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
14. Tacrolimus 1 mg PO Q12H
15. Ursodiol 300 mg PO BID
16. ValGANCIclovir 900 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Influenza A
History of living donor liver transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane). On O2
Discharge Instructions:
Mr. ___,
You were admitted to ___ due to
an influenza infection. You were started on an antiviral
medication called Tamiflu. Your respiratory function improved.
We recommend that complete the entire 5-day course of Tamiflu
and you wear a face mask whenever in public to limit the spread
of the virus that causes the flu. Please follow up with Dr.
___ on ___. It will be determined at that visit if you may
need extended treatment with Tamiflu past the 5-day course. You
will also follow up with Dr. ___ on ___. Thank you for
allowing us to be a part of your care.
Please call the transplant clinic at ___ for fever of
101 or greater, chills, nausea, vomiting, diarrhea,
constipation, inability to tolerate food, fluids or medications,
yellowing of skin or eyes, increased abdominal pain, incisional
redness, drainage or bleeding, dizziness or weakness, decreased
urine output or dark, cloudy urine, swelling of abdomen or
ankles, weight gain of 3 pounds in a day or any other concerning
symptoms.
.
Bring your pill box and list of current medications to every
clinic visit.
.
You will have labwork drawn twice weekly as arranged by the
transplant clinic, with results to the transplant clinic (Fax
___ . CBC, Chem 10, AST, T Bili, Trough Tacro level,
Urinalysis.
.
*** On the days you have your labs drawn, do not take your
Tacrolimus until your labs are drawn. Bring your Tacrolimus with
you so you may take your medication as soon as your labwork has
been drawn.
.
Follow your medication card, keep it updated with any dosage
changes, and always bring your card with you to any clinic or
hospital visits.
.
You may shower. Allow the water to run over your incision and
pat area dry. No rubbing, no lotions or powder near the
incision. You may leave the incision open to the air. The
staples are removed approximately 3 weeks following your
transplant.
.
No tub baths or swimming
.
No driving if taking narcotic pain medications
.
Avoid direct sun exposure. Wear protective clothing and a hat,
and always wear sunscreen with SPF 30 or higher when you go
outdoors.
.
Drink enough fluids to keep your urine light in color. Your
appetite will return with time. Eat small frequent meals, and
you may supplement with things like carnation instant breakfast
or Ensure.
.
Followup Instructions:
___
|
10139992-DS-24 | 10,139,992 | 22,821,243 | DS | 24 | 2123-10-06 00:00:00 | 2123-10-07 09:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with a history of EtOH cirrhosis and
hepatopulmonary syndrome who underwent living donor liver
transplant 7 weeks before admission. He has had a persistent O2
requirement of
___ L since discharge after transplant and has been followed by
pulmonology. Patient was admitted ___ with new ground glass
opacifications in bilateral upper lobes, increased DOE, and
hypoxia. He was found to be Flu A positive and was started on
Tamiflu. His respiratory function improved somewhat to his prior
baseline and was discharged home two days before discharge on
___ to continue
Tamiflu and follow-up with ID today to discuss ongoing course (5
vs. 10 days). However, patient states that a day prior to
admission he began to
feel more fatigued and run-down. Then on presentation to clinic
with Dr ___ became increasingly
hypoxic during the visit and appeared cyanotic. His SaO2 on 6
literes was 72-80%. Patient was increased to 12 liters via NC
and
his O2 sat was 90. He was transferred to ER. Of note his HGB
was
18.8/HCT 55.4 and he was started on aspirin.
Patient currently denies SOB at rest on home O2 levels of 5L and
has an SaO2 of 98%. However, he does become hypoxic while
talking to examiner, which was not the case at the end of
his recent hospital admission. Furthermore, his return to
baseline after exertion is more sluggish than prior. He
endorses
SOB with mild exertion and ongoing nonproductive cough (present
during recent admission also), but denies fever, chills, chest
pain, nausea, vomiting.
Past Medical History:
- ethanol-induced liver cirrhosis, hx alcoholic hepatitis
- ___ living donor liver transplant
- portal hypertension
- esophageal varices ___ banding
- hepatopulmonary syndrome
- thrombocytopenia
- arterial hypertension
- insulin dependent type 2 diabetes mellitus
- obstructive sleep apnea
- depression
- anxiety
- prolonged QT interval
- hypokalemia
Social History:
___
Family History:
___ is one of 18 children. One sibling died from
complications associated with ETOH abuse. One sister has a
seizure disorder. Another sister died aged ___ from glioblastoma.
One brother died aged ___ from lung cancer. His father has
diabetes.
Multiple family members with IBD.
Physical Exam:
VS: T98.8 BP:138/86 HR:86 RR:18 O2Sat:93-5L nc oxymizer
GEN: WD, WN in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR, +S1S2 w no M/R/G
PULM: CTA B/L w no W/R/R, normal excursion, no respiratory
distress at bed
BACK: no vertebral tenderness, no CVAT
ABD: soft, NT, ND, no mass, no hernia, incision scar healing
well
EXT: WWP, no CCE, no tenderness, 2+ B/L ___
NEURO: A&Ox3, no focal neurologic deficits
PSYCH: normal judgment/insight, normal memory, normal
mood/affect
Pertinent Results:
___ 10:20AM BLOOD WBC-7.4 RBC-5.57 Hgb-18.8* Hct-55.2*
MCV-99* MCH-33.8* MCHC-34.1 RDW-13.7 RDWSD-50.2* Plt ___
___ 12:00PM BLOOD WBC-9.4 RBC-5.45 Hgb-18.4* Hct-52.4*
MCV-96 MCH-33.8* MCHC-35.1 RDW-13.4 RDWSD-47.5* Plt ___
___ 06:00AM BLOOD WBC-7.5 RBC-5.22 Hgb-17.8* Hct-50.7
MCV-97 MCH-34.1* MCHC-35.1 RDW-13.5 RDWSD-48.2* Plt ___
___ 06:41AM BLOOD WBC-7.6 RBC-5.10 Hgb-17.4 Hct-49.8 MCV-98
MCH-34.1* MCHC-34.9 RDW-13.3 RDWSD-47.7* Plt ___
___ 04:39AM BLOOD WBC-8.0 RBC-5.10 Hgb-17.6* Hct-49.1
MCV-96 MCH-34.5* MCHC-35.8 RDW-13.2 RDWSD-47.1* Plt ___
___ 06:12AM BLOOD WBC-8.5 RBC-5.07 Hgb-17.8* Hct-49.4
MCV-97 MCH-35.1* MCHC-36.0 RDW-13.4 RDWSD-47.8* Plt ___
___ 07:15AM BLOOD WBC-8.4 RBC-5.21 Hgb-17.6* Hct-50.0
MCV-96 MCH-33.8* MCHC-35.2 RDW-13.2 RDWSD-47.2* Plt ___
___ 10:20AM BLOOD Plt ___
___ 12:00PM BLOOD ___ PTT-29.0 ___
___ 12:00PM BLOOD Plt ___
___ 06:00AM BLOOD ___ PTT-29.6 ___
___ 06:00AM BLOOD Plt ___
___ 06:41AM BLOOD ___ PTT-29.6 ___
___ 06:41AM BLOOD Plt ___
___ 04:39AM BLOOD Plt ___
___ 06:12AM BLOOD Plt ___
___ 07:15AM BLOOD Plt ___
___ 10:20AM BLOOD UreaN-20 Creat-1.0 Na-141 K-4.1 Cl-99
HCO3-23 AnGap-19*
___ 12:00PM BLOOD Glucose-147* UreaN-23* Creat-1.1 Na-139
K-4.3 Cl-102 HCO3-21* AnGap-16
___ 06:41AM BLOOD Glucose-148* UreaN-25* Creat-1.1 Na-142
K-4.7 Cl-105 HCO3-26 AnGap-11
___ 04:39AM BLOOD Glucose-102* UreaN-27* Creat-1.0 Na-142
K-4.3 Cl-105 HCO3-22 AnGap-15
___ 07:15AM BLOOD Glucose-160* UreaN-24* Creat-1.1 Na-143
K-4.8 Cl-103 HCO3-23 AnGap-17
___ 10:20AM BLOOD ALT-46* AST-34 AlkPhos-130 TotBili-0.9
___ 06:00AM BLOOD ALT-40 AST-30 AlkPhos-123 TotBili-1.1
___ 06:41AM BLOOD ALT-38 AST-30 AlkPhos-114 TotBili-0.9
___ 04:39AM BLOOD ALT-37 AST-28 AlkPhos-114 TotBili-0.7
___ 07:15AM BLOOD ALT-40 AST-31 AlkPhos-115 TotBili-0.9
___ 10:20AM BLOOD Albumin-4.3 Calcium-9.4 Phos-2.9 Mg-1.8
___ 06:00AM BLOOD Calcium-9.4 Phos-5.8* Mg-1.6
___ 06:41AM BLOOD Calcium-9.1 Phos-4.4 Mg-1.7
___ 04:39AM BLOOD Calcium-9.3 Phos-4.2 Mg-1.8
___ 07:15AM BLOOD Calcium-9.3 Phos-4.1 Mg-1.5*
Brief Hospital Course:
Mr. ___ living donor liver transplant on ___ was
admitted from the ED on ___ due to shortness of breath,
oxygen desaturation, hypoxia, cough and fatigue, in the setting
of hepatopulmonary syndrome while suffering influenza.
On admission date a CTA was obtained, which ruled out acute
pulmonary embolisms, pneumothorax or pleural effusions. A high
hematocrit was noted his admission H&H , prompting the
initiation of aspirin and a hematology consult. Pulmonary
medicine was also consulted to evaluate and advice on his
respiratory status.
Hematology assessed: "Mr. ___ is a ___ y/o male with history
of liver disease
complicated by hepatopulmonary syndrome ___ a living donor liver
transplant on ___, who has persistent HPS after transplant
on
5 L of nasal oxygen since discharge and recent admission for
hypoxia. Hematology consulted for polycythemia/erythrocytosis.
In the setting of clearly documented hypoxia (SPO2 of 70% at the
appointment) with an underlying disease pathophysiology
involving
intrapulmonary shunting i.e. HPS. It is interesting that the
erythrocytosis seems to have developed post transplant and
although post transplant erythrocytosis has been classically
described with renal transplantation there is experience with
erythrocytosis following OLT as well, but interestingly all
patients in the series had Hep B. ___ et al, Liver Transpl.
___ Apr;19(4):420-4.] However, in this patient's case given
the
ongoing hypoxia this is more likely secondary erythrocytosis
from
persistent hypoxia.
Serum EPO levels can be useful to differentiate primary and
secondary erythrocytosis. However, given extremely low
likelihood
I do not feel there is enough concern for a primary
myeloproliferative disorder to merit further investigation ( eg
Jak 2 testing or EPO levels) at this point.
In patients with primary erythrocytosis phlebotomy and
anticoagulation is often a consideration. However, in patients
with secondary erythrocytosis given this is a compensatory
mechanisim phlebotomy can worsen oxygen delivery and can be
detrimental. Anticoagulation/antiplatelet agents is not usually
a
consideration for patients with secondary erythrocytosis.
SUMMARY OF RECOMMENDATIONS:
1) Do not recoomend further work up for erythrocytosis at this
point.
2) No indication for phlebotomy, if Hematocrit is > 65 and
patient develops symptoms of hyperviscocity this may be a
consideration in the future, but would have to be approached
very
cautiously. We offered a follow up with Hematology for the next
few months, which patient has accepted, we will put in for an
appointment in the next 3 months."
Pulmonary medicine assessed:
___ w/alcoholic cirrhosis c/b hepatopulmonary syndrome ___
liver
transplant ___, chronic hypoxemic respiratory failure with
exertional hypoxemia on ___ home O2, & recent influenza now
admitted with ongoing dyspnea & exertional hypoxemia. CTA chest
unrevealing & seems to be near his baseline respiratory status.
Recommended Oxymizer to reduce exertional hypoxemia & outpatient
pulmonary rehabilitation. Concur with Infectious Disease about
prolonged oseltamivir course.
RECOMMENDATIONS:
- Ambulatory oximetry with Oxymizer on 6LNC
- Outpatient referral to Pulmonary Rehabiliation"
Coordination with ___ diabetes service and Transplant
Infectious diseases services was obtained to optimize diabetes
control and influenza management.
Neuro: The patient was alert and oriented throughout
hospitalization; mild pain was managed with oral Tylenol.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient was admitted with desaturations to the
70-75% range on ambulation, while bumping to the 85-93% on
bedrest. He was short of breath, denying chest pain, or
inspiratory pain. His oxygen saturation on 5L nasal cannula at
rest slowly improved until achieving a maximum of 97%. After
pulmonary evaluation and physical therapy, his oxygen saturation
on ambulation while using 5L on nasal cannula and an oxymizer
improved to 85-95%.
GI/GU/FEN: The patient was tolerated well a regular diet,
persistently passed gas, was not distended or in pain.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none. A 10 day course of oral
oseltamivir was completed during hospitalization. His immune
suppression to prevent rejection remained under control using
tacrolimus, which we gave at 0.5mg every 12 hours, maintaining
blood tacrolimus levels under normal limits.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none. Erythrocytosis was
followed and assessed on a daily basis.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as often 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, including a pulmonary rehabilitation
appointment, with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OSELTAMivir 75 mg PO BID
2. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
3. Atorvastatin 10 mg PO QPM
4. Famotidine 20 mg PO BID
5. Fluconazole 400 mg PO Q24H
6. FLUoxetine 10 mg PO DAILY
7. Magnesium Oxide 400 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Mycophenolate Mofetil 1000 mg PO BID
10. PredniSONE 5 mg PO DAILY
11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
12. Ursodiol 300 mg PO BID
13. ValGANCIclovir 900 mg PO Q24H
14. Sodium Polystyrene Sulfonate 15 gm PO ASDIR hyperkalemia
15. Tacrolimus 1 mg PO Q12H
16. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Glargine 16 Units Breakfast
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. Tacrolimus 0.5 mg PO Q12H
we decreased your dose on this hospitalization based on your
tacrolimus levels
RX *tacrolimus 0.5 mg 1 capsule(s) by mouth every twelve (12)
hours Disp #*60 Capsule Refills:*0
4. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
5. Atorvastatin 10 mg PO QPM
6. Famotidine 20 mg PO BID
end date ___. Fluconazole 400 mg PO Q24H
end date ___
8. FLUoxetine 10 mg PO DAILY
9. Magnesium Oxide 400 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Mycophenolate Mofetil 1000 mg PO BID
12. PredniSONE 2.5 mg PO DAILY
you should decrease your dose from 5mg to 2.5mg on ___
per your scheduled taper
Tapered dose - DOWN
13. Sodium Polystyrene Sulfonate 15 gm PO ASDIR hyperkalemia
14. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
15. Ursodiol 300 mg PO BID
16. ValGANCIclovir 900 mg PO Q24H
17.Pulmonary Rehabilitation
Nasal cannula with oxymizer
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hepatopulmonary syndrome, hypoxia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - with assistance and O2
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ due to
an influenza infection and low oxygen saturations. You were
continued on an antiviral medication called Tamiflu which you
took your last doses of today ___. Your respiratory function
improved. You should also follow-up with Dr. ___ in clinic on
___. An appointment will be made for you through the office,
but if you do not hear from the office, please call to confirm.
Thank you for allowing us to be a part of your care.
Please call the transplant clinic at ___ for fever of
101 or greater, chills, nausea, vomiting, diarrhea,
constipation, inability to tolerate food, fluids or medications,
yellowing of skin or eyes, increased abdominal pain, incisional
redness, drainage or bleeding, dizziness or weakness, decreased
urine output or dark, cloudy urine, swelling of abdomen or
ankles, weight gain of 3 pounds in a day or any other concerning
symptoms.
Bring your pill box and list of current medications to every
clinic visit.
You will have labwork drawn twice weekly as arranged by the
transplant clinic, with results to the transplant clinic (Fax
___. CBC, Chem 10, AST, T Bili, Trough Tacro level,
Urinalysis.
*** On the days you have your labs drawn, do not take your
Tacrolimus until your labs are drawn. Bring your Tacrolimus with
you so you may take your medication as soon as your labwork has
been drawn.
Follow your medication card, keep it updated with any dosage
changes, and always bring your card with you to any clinic or
hospital visits.
You may shower. Allow the water to run over your incision and
pat area dry. No rubbing, no lotions or powder near the
incision. You may leave the incision open to the air.
No tub baths or swimming
No driving if taking narcotic pain medications
Avoid direct sun exposure. Wear protective clothing and a hat,
and always wear sunscreen with SPF 30 or higher when you go
outdoors.
Drink enough fluids to keep your urine light in color. Your
appetite will return with time. Eat small frequent meals, and
you may supplement with things like carnation instant breakfast
or Ensure.
Followup Instructions:
___
|
10139992-DS-28 | 10,139,992 | 23,325,882 | DS | 28 | 2124-02-12 00:00:00 | 2124-02-13 08:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, nausea, vomiting
Major Surgical or Invasive Procedure:
Liver Biopsy (___)
ERCP with Biliary Stent Placement (___)
History of Present Illness:
Mr. ___ is a ___ y/o male with EtOH cirrhosis c/b
hepatopulmonary syndrome s/p living donor liver transplant
(___) c/b influenza, mild acute rejection ___ and
___ presenting with fevers, nausea, and vomiting.
Mr. ___ is followed by Dr. ___ and underwent
liver transplant on ___. Post transplant course c/b
influenza infection. In ___, he had mild acute cellular
rejection for which he was treated with solumedrol, which was
transitioned to prednisone. He underwent ERCP in late ___ for
removal of retained CBD stent.
Given persistently elevated LFTs, he underwent a liver biopsy on
___ which was again consistent with mild acute rejection
--
"Mild portal predominately mononuclear inflammation comprised of
lymphocytes with scattered plasma cells and bile ducts with
focal
lymphocytic cholangitis, bile duct damage and associated
neutrophils". He was asked to be admitted to the hospital, and
was treated with solumedrol 1g IV x3 doses. His
immunosuppressant
regimen was modified to increase mycophenolate to 1500 mg BID
and
tacrolimus to 3g BID. He was also discharged on prednisone 20 mg
daily. For uncontrolled DM2, ___ was consulted and
recommended
NPH 20U qAM with prednisone 20 mg and daily lantus 20U qAM +
Humalog ___ qAC.
After discharge from the hospital on ___, he was seen in clinic
for f/up on ___. At the time, he was noted to be feeling
well.
He had LFTs drawn as an outpatient during this week, and due to
rising LFTs on ___, was scheduled for a liver biopsy on ___.
On ___, the day prior to admission, the patient noticed a new
patchy pruritic rash on his neck and trunk after moving blocks
of
cobblestone to repair his driveway. The rash disappeared after
showering. Later that night, he developed new subjective
fevers/chills and vomited twice, which he described as
orange-brown but without gross blood. He had no abdominal pain
or
pain elsewhere during this episode. Also denies chest pain,
cough, headache, diarrhea. At 5am, he presented to the ___ ED
as he was scheduled at ___ for a liver biopsy to evaluate for
transplant rejection later that day.
In the ED, initial VS were T 98.1, HR 92, BP 131/67, RR 22, O2
98% RA. Exam not documented in ED. Labs notable for WBC 5.5, hgb
15.6, plt 86, Mg 1.1, Cr 0.8, ALT 131, AST 92, Alk phos 185,
Tbili 2.2.
EKG with NSR, normal axis, TWI in V1, no ischemic changes.
Imaging notable for:
CXR ___:
No acute cardiopulmonary abnormality.
Abdominal US ___:
Patent hepatic vasculature with appropriate waveforms, overall
similar to prior.
Transplant surgery and Hepatology were consulted. Hepatology
recommended a liver biopsy which was performed on ___.
He received insulin in the ED and was transported to the floor.
On arrival to the floor, the patient endorses fatigue but
otherwise reports feeling well. He denies any headache, nausea,
abdominal pain, or changes in his appetite or bowel movements.
Since his transplant, he has had two episodes of acute rejection
in ___ and ___ which were identified by LFT elevations.
He denies having any symptoms during those episodes.
He reports traveling to ___ two weeks prior with his dog,
which was bitten by ticks, but denies any tick bites on himself.
He denies any other travel or sick contacts.
Past Medical History:
- ethanol-induced liver cirrhosis, hx alcoholic hepatitis
- ___ living donor liver transplant
- portal hypertension
- esophageal varices s/p banding
- hepatopulmonary syndrome
- thrombocytopenia
- HTN
- insulin dependent type 2 diabetes mellitus
- obstructive sleep apnea
- depression
- anxiety
- prolonged QT interval
- hypokalemia
Social History:
___
Family History:
___ is one of 18 children. One sibling died from
complications associated with ETOH abuse. One sister has a
seizure disorder. Another sister died aged ___ from glioblastoma.
One brother died aged ___ from lung cancer. His father has
diabetes.
Multiple family members with IBD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
Vitals: T 98.1, HR 92, BP 131/67, RR 22, O2 98% RA
General: Resting in bed, no acute distress
HEENT: Sclera anicteric, moist mucous membranes
Neck: No JVD, no LAD
Lungs: Clear to auscultation bilaterally
CV: Regular S1 and S2, no murmurs
GI: Well-healed scars from transplant surgery. +BS. Soft,
non-tender, non-distended.
Ext: Warm, no edema, several scattered ecchymosis
Neuro: AOx3, conversational, moving all extremities
spontaneously
Pertinent Results:
ADMISSION/DISCHARGE LABS:
___ 05:13AM BLOOD WBC-3.1* RBC-4.36* Hgb-14.9 Hct-41.8
MCV-96 MCH-34.2* MCHC-35.6 RDW-12.4 RDWSD-43.2 Plt ___
___ 05:13AM BLOOD Plt ___
___ 05:13AM BLOOD ___ PTT-26.4 ___
___ 05:13AM BLOOD Glucose-127* UreaN-17 Creat-0.8 Na-143
K-4.2 Cl-105 HCO3-23 AnGap-15
___ 05:13AM BLOOD ALT-71* AST-47* AlkPhos-137* TotBili-1.1
___ 05:13AM BLOOD Albumin-3.5 Calcium-8.3* Phos-3.1 Mg-1.6
___ 05:13AM BLOOD tacroFK-11.0
___ 05:13AM BLOOD
___ 02:36PM URINE HOURS-RANDOM
___ 02:36PM URINE UHOLD-HOLD
___ 02:36PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 02:36PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-300* KETONE-10* BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 02:36PM URINE RBC-2 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 02:36PM URINE MUCOUS-RARE*
___ 06:41AM LACTATE-1.2
___ 06:33AM GLUCOSE-171* UREA N-18 CREAT-0.8 SODIUM-136
POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-20* ANION GAP-18
___ 06:33AM estGFR-Using this
___ 06:33AM ALT(SGPT)-131* AST(SGOT)-92* ALK PHOS-185*
TOT BILI-2.2*
___ 06:33AM LIPASE-14
___ 06:33AM ALBUMIN-3.9 CALCIUM-8.7 PHOSPHATE-2.7
MAGNESIUM-1.1*
___ 06:33AM tacroFK-> 30.0
___ 06:33AM WBC-5.5 RBC-4.72 HGB-15.6 HCT-44.4 MCV-94
MCH-33.1* MCHC-35.1 RDW-12.3 RDWSD-42.6
___ 06:33AM NEUTS-71.7* LYMPHS-9.9* MONOS-14.1* EOS-0.2*
BASOS-0.4 IM ___ AbsNeut-3.92 AbsLymp-0.54* AbsMono-0.77
AbsEos-0.01* AbsBaso-0.02
___ 06:33AM PLT COUNT-86*
___ 08:05AM GLUCOSE-99
___ 08:05AM UREA N-16 CREAT-0.7 SODIUM-143 POTASSIUM-3.7
CHLORIDE-103 TOTAL CO2-26 ANION GAP-14
___ 08:05AM ALT(SGPT)-141* AST(SGOT)-120* ALK PHOS-170*
TOT BILI-1.3
___ 08:05AM ALBUMIN-4.1 CALCIUM-9.2 PHOSPHATE-3.7
MAGNESIUM-1.6
___ 08:05AM tacroFK-13.0
___ 08:05AM WBC-6.6 RBC-4.67 HGB-15.7 HCT-45.1 MCV-97
MCH-33.6* MCHC-34.8 RDW-12.6 RDWSD-44.2
___ 08:05AM NEUTS-77.4* LYMPHS-10.0* MONOS-8.3 EOS-1.1
BASOS-0.6 IM ___ AbsNeut-5.14 AbsLymp-0.66* AbsMono-0.55
AbsEos-0.07 AbsBaso-0.04
___ 08:05AM PLT COUNT-105*
___ 08:05AM ___
IMAGING:
MRCP ___
IMPRESSION:
1. Status post liver transplant with mild narrowing of the
biliary system near the anastomosis and minimal intrahepatic
biliary ductal dilatation. No high-grade stenosis. Biliary
stent in situ. No focal lesion.
2. Mildly heterogeneous right hepatic enhancement may reflect
known mild
cholangitis. No focal fluid collection.
ERCP ___ Narrowing of the right anterior/posterior branch,
plastic stent in the right anterior branch, could not cannulate
posterior branch
DUPLEX ___
IMPRESSION:
Patent hepatic vasculature with appropriate waveforms, overall
similar to
prior.
CXR ___
IMPRESSION:
No acute cardiopulmonary abnormality.
Liver biopsy ___
PATHOLOGIC DIAGNOSIS:
Liver, allograft, needle core biopsy:
-Features consistent with ongoing acute cellular rejection
including, lymphocytic cholangitis with
focally prominent dystrophic bile duct damage, portal venous
endothelialitis, mild portal mononuclear
inflammation and rare central venular subendothelial lymphocytic
infiltration without hemorrhage or
definitive ___. Scattered lipofuscin-laden
macrophages present, consistent with
prior/ongoing injury.
-___ fibrohistiocytic focus with hepatocyte dropout,
focal necrosis, karyorrhectic debris and
few neutrophils, raising the possibility of a concomitant
infectious process (including bacterial, viral,
fungal and mycobacterial).
-Prominent bile ductular proliferation with associated
neutrophils and mild intrahepatocytic
cholestasis. See note.
-C4d immunohistochemical stain is negative, with satisfactory
control.
-CMV and HSV immunohistochemical stains are negative, with
satisfactory controls; AFB and GMS
stains are negative for acid fast bacilli and fungi, with
satisfactory controls.
-Trichrome stain demonstrates no fibrosis; iron stain is
negative for iron deposition.
Note: The rejection is difficult to grade in the clinical
context of recent treatment for acute cellular
rejection. The bile ductular proliferation with associated
neutrophils is greater than that typically seen
due to acute cellular rejection alone, and the possibility of
antibody mediated rejection cannot be
excluded (in spite of previously negative immunohistochemical
staining for C4d); further clinical
correlation with anti-donor serum antibodies is recommended.
Alternatively, the differential for these
additional biliary features includes sepsis and ascending
cholangitis, and further clinical evaluation
to exclude an infectious etiology is needed, particularly given
the above described inflammatory
___
Department of Pathology Patient: ___ 2 of 2
focus; biliary ischemia or obstruction appear less likely
clinically.
Compared to the most recent biopsy (___), the lymphocytic
cholangitis with dystrophic duct
damage and bile ductular proliferation with associated
neutrophils are more prominent. Additionally,
there has been the interval development of mild cholestasis and
the above described inflammatory
focus.
Brief Hospital Course:
PATIENT SUMMARY:
================
Mr. ___ is a ___ y/o gentleman with EtOH cirrhosis c/b
hepatopulmonary syndrome s/p living donor liver transplant
(___) c/b influenza, mild acute rejection ___ and
___ who presented with cholangitis and acute liver
rejection.
ACTIVE ISSUES:
==============
# Cholangitis
Patient presented with new onset fevers, nausea, vomiting, and
hyperbilirubinemia, with liver biopsy on ___ consistent with
cholangitis. The patient was empirically started on vancomycin
(discontinued ___ and zosyn. ERCP on ___ revealed stricture
of the right anterior biliary duct, which was treated with stent
placement. The right posterior duct could not be cannulated,
necessitating plan for PTBD. However, the patient showed
significant clinical improvement with initiation of antibiotics
and ERCP. AST, ALT, alkaline phosphatase, and bilirubin
downtrended to baseline. Decision was made to cancel PTBD given
clinical stability and resolution of transaminitis and
hyperbilirubinemia. MRCP on ___ confirmed patency of biliary
stent and plan was made to treat for a 14-day course of
cholangitis. He was continued on Zosyn while inpatient. On ___,
___ was placed. Patient was given test dose of Ertapenem 1g IV,
which was tolerated. Mr. ___ complete a 14 day
antibiotic course (___) on Ertapenem 1g IV Daily for ease
of dosing.
# EtOH cirrhosis s/p LDLT ___
# Concern for acute rejection:
The patient's presentation with fever, nausea, and vomiting were
concerning for acute rejection. Initial pathology results were
suggestive of mild acute rejection, but ATG was held given
active infection requiring treatment. The patient subsequently
improved clinically as described above, and thus suspicion was
decreased for rejection as the etiology of his symptoms. Final
pathology read from ___ biopsy showed acute cellular
rejection,
negative C4d, CMV, HSV. Given his history of multiple acute
rejection episodes, HLA antigens testing and DSA were sent.
Pending on discharge. His prednisone tapered from 17.5 mg to
15mg PO daily while here. The steroid taper will be managed by
Dr. ___ as an outpatient at follow up. Patient was advised not
to decrease his prednisone any further without confirmation from
his liver doctors. ___ levels were elevated while so his
home dose was reduced to 2 mg Q12H. He continued on home Bactrim
and valgan for ppx. ___ level on d/c: 11.0.
# Epigastric Pain
Following ERCP on ___, the patient reported new epigastric
pain. He had never had this pain before. It lasted seconds to
minutes, and occurred after eating or ingesting medication. His
vital signs remained stable, with no concerning abdominal exam
findings (no rebound, no TTP). EGD (___) showed small ulcer
in duodenal bulb. Pain assessed as likely secondary to a small
duodenal ulcer noted on EGD in ___, and was treated with an
H2 blocker. Pain resolved on the day of discharge.
#Diarrhea
On the first day of his hospital stay, Mr. ___ developed
watery diarrhea. He had ___ episodes of diarrhea daily. C. Diff
PCR results were negative. Once patient resumed his full diet
over the last two days of his hospital stay, his stools became
formed. Given that patient was afebrile, had stable WBC, and had
improvement with diet, the etiology of his diarrhea is likely a
side effect of his antibiotic regimen and changing diet.
CHRONIC ISSUES:
===============
# Thrombocytopenia
# Alcoholic Cirrhosis s/p living donor transplant (___):
Patient has had multiple complications, including portal
hypertension, esophageal varices s/p banding, hepatopulmonary
syndrome, and thrombocytopenia. S/p living donor liver
transplantation on ___ c/b acute rejection (see above).
Abd ultrasound this admission revealed patent hepatic
vasculature.
# DM2: Patient has had uncontrolled diabetes in the past.
Patient recently saw ___ outpatient with uptitration of his
home insulin regimen. While here, his insulin was downtitrated
in setting of prolonged NPO status for procedures. Discharge
insulin regimen: NPH 30 units in the morning, Lantus 20 units in
the morning, Humalog to ___ as per ___ recs during his
last outpatient visit.
# HLD:
Patient continued on home aspirin and atorvastatin.
TRANSITIONAL ISSUES:
====================
# Cholangitis
[] 14 day antibiotic course (___) on Ertapenem 1g IV
Daily.
[] Pending blood cultures on discharge
# ETOH Cirrhosis S/p LDLT
# Mild Acute Cellular Liver Rejection
[] Follow up labs (CBC, BUN/Cr, coags, electrolytes, LFTs,
tacrolimus level) to be drawn on ___. Please fax results to
___.
[] Decreased Tacrolimus dose from 3mg BID to 2mg BID. MMF
continued at 1500mg BID. Discharge ___ level 11.0
[] Prednisone tapered from 17.5 mg to 15mg PO/Daily. The steroid
taper will be managed by Dr. ___ as an outpatient at follow
up. Patient advised not to decrease his prednisone any further
until cleared by his liver doctors.
#DM Type II
[]Per ___, NPH 30 units in the morning, Lantus 20 units in
the morning, Humalog to ___ + adjust Humalog SSI. Treat low
blood sugars <70 with 15gm or 30gm carbs.
# Code Status: Presumed full code
# HCP Contact Information: ___ (brother) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ValGANCIclovir 900 mg PO DAILY
2. Mycophenolate Mofetil 1500 mg PO BID
3. PredniSONE 17.5 mg PO DAILY
4. Famotidine 20 mg PO Q12H
5. insulin NPH isoph U-100 human 100 unit/mL subcutaneous QAM
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 10 mg PO QPM
8. Magnesium Oxide 400 mg PO DAILY
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Tacrolimus 3 mg PO BID
11. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
12. Sodium Polystyrene Sulfonate 15 gm PO AS DIRECTED FOR
HYPERKALEMIA
13. Ursodiol 300 mg PO BID
14. Glargine 20 Units Breakfast
Humalog 10 Units Breakfast
Humalog 12 Units Lunch
Humalog 12 Units Dinner
NPH 28 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose
RX *ertapenem 1 gram 1 g IV daily Disp #*10 Vial Refills:*0
2. Glargine 20 Units Breakfast
Humalog 10 Units Breakfast
Humalog 12 Units Lunch
Humalog 12 Units Dinner
NPH 30 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
3. PredniSONE 15 mg PO DAILY
4. Tacrolimus 2 mg PO Q12H
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 10 mg PO QPM
7. Famotidine 20 mg PO Q12H
8. Mycophenolate Mofetil 1500 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
-Acute liver transplant rejection
-Cholangitis
Secondary Diagnoses:
-T2DM
-Thrombocytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear, Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for signs of bile duct system infection and
mild liver transplant rejection.
What was done for me while I was in the hospital?
- We placed a stent in your bile duct to help it drain and got
imaging to confirm your bile duct system was no longer dilated.
- We treated you with antibiotics and placed a special catheter
(PICC) so that you could continue to take your antibiotics at
home.
- We adjusted the dose of your immunosuppressive
medications(Tacrolimus and Mycophenolate mofetil).
- We got a biopsy of your liver tissue to evaluate for mild
liver transplant rejection and continued treatment for it.
What should I do when I leave the hospital?
- You should continue to take your medications as prescribed.
- Please get labs drawn on ___. Dr. ___ follow
these up.
- You should follow up with your hepatologist Dr. ___ will
help manage your prednisone taper.
- You should follow-up with your endocrinologist for management
of your diabetes while on steroids.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10140454-DS-9 | 10,140,454 | 27,352,547 | DS | 9 | 2173-09-25 00:00:00 | 2174-01-22 14:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Pain, cecal mass
Major Surgical or Invasive Procedure:
___: exploratory laparotomy, Right colectomy, fiducial
placement, and right ureteral stent placement.
History of Present Illness:
(History was largely obtained from ACS consult note
yesterday and verified with patient.) Mr. ___ is a ___ with
no known significant PMH who presented initially to ___ with ___ days of RLQ pain radiating into his flank. He
denies any prior episodes of the pain. Reports pain is
constant,
___. He reports no bowel movements for 3 days with diminished
flatus which is what prompted him to initially present to the
ED.
He denies any nausea, vomiting, BRBPR, or melana. He does
report
a fever of 102.2 at home yesterday. At ___ a CT scan of
his abdomen was obtained revealing a mass in the cecum
suspicious
for a perforated carcinoma with evidence of metastatic disease.
He was transferred to ___ for further evaluation.
Past Medical History:
PMH: none
PSH: Transsphenoidal pituitary resection, left inguinal hernia
repair
Social History:
___
Family History:
Mother with lung cancer
Physical Exam:
Admission Physical Exam:
Vitals: T 99.0 P 64 BP 118/62 RR 18 O2 Sat 93% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: normal effort/excursion
ABD: soft, obese, tender to palpation in RLQ without rebound or
guarding
Ext: WWP, no CCE
Discharge Physical Exam:
Pertinent Results:
___ 11:40PM BLOOD WBC-25.2* RBC-4.77 Hgb-13.4* Hct-41.8
MCV-88 MCH-28.1 MCHC-32.1 RDW-13.9 Plt ___
___ 06:13AM BLOOD WBC-24.0* RBC-4.44* Hgb-12.4* Hct-39.4*
MCV-89 MCH-28.0 MCHC-31.6 RDW-13.8 Plt ___
___ 07:10AM BLOOD WBC-20.7* RBC-4.46* Hgb-12.3* Hct-39.3*
MCV-88 MCH-27.6 MCHC-31.3 RDW-13.8 Plt ___
___ 06:00AM BLOOD WBC-16.6* RBC-4.47* Hgb-12.6* Hct-39.0*
MCV-87 MCH-28.3 MCHC-32.4 RDW-14.3 Plt ___
___ 11:40PM BLOOD Neuts-87.5* Lymphs-7.1* Monos-4.6 Eos-0.5
Baso-0.3
___ 06:00AM BLOOD ___ PTT-26.7 ___
___ 11:40PM BLOOD Glucose-97 UreaN-13 Creat-0.9 Na-136
K-4.2 Cl-98 HCO3-25 AnGap-17
___ 11:40PM BLOOD ALT-29 AST-23 AlkPhos-103 TotBili-1.5
___ 06:00AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.2
___ 11:40PM BLOOD Albumin-3.3* Calcium-8.2* Phos-3.8 Mg-2.4
___ 06:00AM BLOOD CEA-9.1*
___ 11:50PM BLOOD Lactate-1.2
___: There are multiple bilateral pulmonary nodules
consistent with metastatic disease. There is no evidence of
focal consolidation, pleural effusion, or pneumothorax. The
cardiac silhouette is mildly enlarged and aorta is slightly
tortuous. Osseous structures are unremarkable
CT A/P OSH: Heterogeneous mass at the cecal tip and terminal
ileum with more ill-defined hypodensity and stranding in the
retrocolic region suspicious for a perforated carcinoma. No
contrast extravasation or free air noted. Appendix is dilated.
Multiple hepatic and pulmonary nodules consistent with
metastatic
disease. Lucency in the L4 vertebral body
Brief Hospital Course:
The patient was admitted to the Colorectal Service. He was
placed on bowel rest, IV hydration, and Zosyn therapy. His WBC
was initially 25. Risks and benefits were explained to the
patient. He was taken to the OR on ___ for an exploratory
laparotomy and the was epidural split in PACU. On ___ Pain
controlled on epidural the patient tolerated sips of clear
liquids, however required a 500cc bolus UOP <20/hr. On ___
500cc bolus for low UOP w good effect, Cr up to 1.4, lopressor
stopped, and the patient was tolerating sips of clear liquids.
On ___ the patient was tolerating clear liquids. Creatinine
was noted to be 1.5. The patient was ambulating well. On
___ the patient accidentally self removed the ureteral
stent. His creatinine was monitored closely and on ___
Creatinine wsa 1.5, FeNa 3%, UA neg, and the patient stopped
Zosyn therapy. On ___ the patient was passing flatus after
eating eggs/toast related to "food stuck" midesophagus. The
Epidural catheter was removed and the patient reported good pain
control. On ___ the Foley catheter was removed and the
patient voided. The patient's dysphagia resolved after
intravenous PPI and the patient was discharged home on the
morning of ___ in good condition. The patient's elevated
white blood cell count was attributed to his cancerous mass. The
patient was counciled by Dr. ___ a referral was made to an
outside oncologist by Dr. ___.
Medications on Admission:
None
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) for 4 days: do not take more than 4000mg of tylenol
in 24 hours.
2. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for pain for 5 days: do not drink alcohol or drive a
car while taking this medication.
Disp:*35 Tablet(s)* Refills:*0*
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Colon Cancer
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 after a Right Sided Colectomy
for surgical management of your colon cancer. You have recovered
from this procedure well and you are now ready to return home.
Samples from your colon were taken and this tissue has been sent
to the pathology department for analysis. You will receive these
pathology results at your follow-up appointment. If there is an
urgent need for the surgeon to contact you regarding these
results they will contact you before this time. You have
tolerated a regular diet, passing gas and your pain is
controlled with pain medications by mouth. You may return home
to finish your recovery. You have a persistently elevated white
blood cell count which could be related to the process of the
mass in your colon. Dr. ___ has talked with an outside medical
oncologist who you know Dr. ___ will see you within the
next week to begin treatment for your cancer. You should bring
with you the pathology report and operative note from your
procedure as well as your ct scan images from the outside
hospital for him to review. His office will contact you. During
your admission you developed heart burn which caused you to have
the sensation of not being able to swallow, you will started on
Protonix which helped these symptoms. You may continue this
medication.
Please monitor Movement prior to your discharge which is
acceptable, however it is important that you have a bowel
movement in the next ___ days. After anesthesia it is not
uncommon for patients to have some decrease in bowel function
but your should not have prolonged constipation. Some loose
stool and passing of small amounts of dark, old appearing blood
are expected however, if you notice that you are passing bright
red blood with bowel your bowel function closely. If you are
passing loose stool without improvement please call the office
or go to the emergency room if the symptoms are severe. If you
are taking narcotic pain medications there is a risk that you
will have some constipation. Please take an over the counter
stool softener such as Colace, and if the symptoms does not
improve call the office. If you have any of the following
symptoms please call the office for advice or go to the
emergency room if severe: increasing abdominal distension,
increasing abdominal pain, nausea, vomiting, inability to
tolerate food or liquids, prolonged loose stool, or
constipation.
You have a long vertical incision on your abdomen that is closed
with staples. This incision can be left open to air or covered
with a dry sterile gauze dressing if the staples become
irritated from clothing. The staples will stay in place until
your first post-operative visit at which time they can be
removed in the clinic, most likely by the office nurse. Please
monitor the incision for signs and symptoms of infection
including: increasing redness at the incision, opening of the
incision, increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if you develop a
fever. Please call the office if you develop these symptoms or
go to the emergency room if the symptoms are severe. You may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. ___ Dr. ___. You may
gradually increase your activity as tolerated but clear heavy
exercise with Dr. ___. Please continue to wear your abdominal
binder when out pf bed. This is very important to prevent
hernia.
You will be prescribed a small amount of the pain medication
oxycodone. Please take this medication exactly as prescribed.
You may take Tylenol as recommended for pain. Please do not take
more than 4000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck
Followup Instructions:
___
|
10140532-DS-15 | 10,140,532 | 28,085,231 | DS | 15 | 2144-07-13 00:00:00 | 2144-07-13 16:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year old man with polycystic kidney disease who
presents with acute onset right sided flank pain and hematuria.
Patient has autosomal polycystic kidney disease with family
history (father). He was being followed by a pediatric and then
recently an adult nephrologist (Dr ___ at ___.
He recently moved to ___ to attend ___.
HE reports at baseline, he intermittently has back "tightness"
with hematuria, that usually occurs in 3 day episodes. He
reports back pain worse than usual for the past week. He woke up
last night with severe spasms of flank pain, bilateral,
associated with hematuria. Also nauseous and vomiting. Denies
fever, chills. Worsened with movement or deep inspiration.
In ED, VS: 97.3 86 166/95 18 100% RA
On exam, with +RCVAT, mod TTP of RLQ, RUQ
Labs showed UA with large leuk esterase, >182 WBC, pos nitrites.
Cr 1.6
CT showed no evidence of obstructing renal stone, as clinically
questioned. No
ureteral or bladder stones. Polycystic appearance of the
bilateral kidneys with multiple punctate nonobstructive
calcifications bilaterally.
Given
___ 14:52 IV Ondansetron 4 mg
___ 14:52 PO Acetaminophen 1000 mg
___ 14:52 IVF 1000 mL NS 1000 mL
___ 18:41 IV CeftriaXONE 1 gm
___ 18:41 IVF 1000 mL NS 1000 mL
___ 20:57 PO/NG Acetaminophen 1000 mg
Transfer VS: 99.3 73 165/85 16 97% RA
On arrival to floor, reports pain worse after bumpy ambulance
ride. Reports right sided flank tenderness.
Past Medical History:
ADPKD
Secondary HTN on enalapril
Social History:
___
Family History:
Father has ADPKD
Physical Exam:
Admission PE
Gen: NAD, sleeping comfortably
HEENT: NCAT, EOMI
Neck: No JVD
CV: RRR, nl S1 S2, no m/r/g
Lungs: Clear to auscultation bilaterally, no wheezing or rales
Abd: right sided CVA tenderness to palpation
Ext: No edema
Skin: No rashes
Psych: Full range of affect
MSK: No joint swelling
Discharge PE:
Vitals: 98.3 151 / 73 73 16 99 RA
Gen: NAD, sitting in chair
Pulm: CTAB
CV: RRR, no m
Abd: soft, NT, ND + BS
Back: mild right sided CVA tenderness
Extrem: warm, no edema
GU: no foley
Skin: no rash
Neuro: A+Ox3, speech fluent
Pertinent Results:
___ 03:30PM URINE UHOLD-HOLD
___ 03:30PM URINE COLOR-Red APPEAR-Cloudy SP ___
___ 03:30PM URINE BLOOD-LG NITRITE-POS PROTEIN->300
GLUCOSE-NEG KETONE-15 BILIRUBIN-LG UROBILNGN-1 PH-8.5* LEUK-LG
___ 03:30PM URINE MUCOUS-FEW
___ 01:30PM estGFR-Using this
___ 01:30PM LIPASE-22
___ 01:30PM WBC-17.0* RBC-4.41* HGB-13.2* HCT-41.2 MCV-93
MCH-29.9 MCHC-32.0 RDW-13.6 RDWSD-46.2
___ 01:30PM NEUTS-91.7* LYMPHS-2.8* MONOS-4.9* EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-15.62* AbsLymp-0.48* AbsMono-0.83*
AbsEos-0.00* AbsBaso-0.01
CT:1. No evidence of obstructing renal stone, as clinically
questioned. No
ureteral or bladder stones.
2. Polycystic appearance of the bilateral kidneys with multiple
punctate
nonobstructive calcifications bilaterally.
3. No definite acute findings.
___ 3:30 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Discharge labs:
___ 06:55AM BLOOD WBC-11.3* RBC-3.62* Hgb-10.8* Hct-33.4*
MCV-92 MCH-29.8 MCHC-32.3 RDW-13.0 RDWSD-43.3 Plt ___
___ 06:55AM BLOOD Glucose-98 UreaN-17 Creat-1.5* Na-136
K-4.8 Cl-98 HCO3-30 AnGap-13
Brief Hospital Course:
Patient is a ___ year old man with polycystic kidney disease who
presents with acute onset right sided flank pain and hematuria.
# Polycystic kidney disease with infected cyst
# Non obstructive renal calculi
Patient presented with acute flank pain, leukocytosis,
hematuria, positive UA, concerning for pyelonephritis. He was
initially treated with IV ceftriaxone, but when urine culture
was negative it seemed more likely that he might have an
infected renal cyst, so he was changed to ciprofloxacin which
has better cyst penetration than the cephalosporins. His
leukocytosis, pain and hematuria gradually improved. Blood and
urine cultures remained negative.
-Continue ciprofloxacin for total 4 week course given concern
for infected cyst
-Discharged with short course of oxycodone for pain, ___
reviewed and he has not in the system.
-Outpatient nephrology follow-up
# ___ on CKD stage III: Per outpatient nephrologist records his
baseline creatinine is 1.4. He developed ___ with creatinine
peaking at 1.9, he was given IV fluids and his enalapril was
held with improvement in creatinine to baseline.
# Secondary HTN: Held enalapril in the setting of acute renal
failure and restarted on discharge.
#Dispo: home without services
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enalapril Maleate 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 24 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*48 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*8 Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN constipation
6. Enalapril Maleate 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Pyelonephritis
Acute renal failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___
___ were hospitalized with right flank pain and diagnosed with
an infected kidney cyst. ___ were treated with antibiotics, pain
medications and fluids and your symptoms gradually improved.
Please follow up with nephrology as scheduled.
Followup Instructions:
___
|
10140907-DS-12 | 10,140,907 | 20,057,418 | DS | 12 | 2133-04-14 00:00:00 | 2133-04-18 09:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left face and arm weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old right-handed man who presents with
left face and arm weakness since awakening at 6 AM this morning.
He went to bed at 11 ___ last night feeling normal. He has a
history of hypertension, diabetes, and hyperlipidemia. He is not
on anti-thrombotic therapy. When he woke up, his wife with whom
he lives noticed the facial weakness. He originally
presented to ___ where he underwent a noncontrast
head CT which may have shown some subtle signs of ischemia in
the right hemisphere, and he subsequently was transferred to
___ for further care. A Code Stroke was called and his initial
NIHSS was 3; on repeat testing it is 5. He arrived outside the
window for IV or IA tPA so vascular imaging was obtained but a
perfusion study was not performed. He has never had these
symptoms before.
He additionally has a right frontal "steady" and "achy" headache
that is ___ in severity. He does not usually have many
headaches. He denies any cardiac symptoms such as chest pain,
dyspnea, palpitations, diaphoresis or nausea.
Past Medical History:
Cardiovascular - HTN, HL
Endocrine - DM2
No stroke, migraines, or cardiovascular disease.
Social History:
___
Family History:
There's no family history of stroke, myocardial infarction, deep
vein thrombosis, pulmonary embolism, recurrent miscarriages, or
rheumatologic disease. His mother had diabetes and hypertension.
There's otherwise no history of neurologic disease.
Physical Exam:
VS HR: 64 BP: 164/97 RR: 16 SaO2: 100% RA
General: NAD, lying in bed comfortably, well appearing
middle-aged dark-skinned man.
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity, no meningismus, no
carotid/subclavian/vertebral bruits
Cardiovascular: RRR, no M/R/G
Pulmonary: Equal air entry bilaterally, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema, palpable radial/dorsalis pedis
pulses
Skin: No rashes or lesions, but dry hairless lower legs
(half-way
down)
___ Stroke Scale - Total [5]
1a. Level of Consciousness - 0
1b. LOC Questions - 0
1c. LOC Commands - 0
2. Best Gaze - 0
3. Visual Fields - 0
4. Facial Palsy - 2
5a. Motor arm, left - 1
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 - 1
11. Extinction and Neglect - 1
Neurologic Examination:
- Mental Status - Awake, drowsy, oriented x 3. Attention to
examiner easily attained and maintained. Concentration
maintained
when recalling months backwards. Recalls a coherent history.
Structure of speech demonstrates fluency with full sentences,
intact repetition, and intact verbal comprehension. Content of
speech demonstrates intact naming (high and low frequency) and
no
paraphasias. Normal reading. Normal prosody. Mild dysarthria for
mouth sounds. No apraxia. No left-right agnosia.
- Cranial Nerves - [II] PERRL 3->1.5 brisk. VF full to number
counting. [III, IV, VI] EOMI, no nystagmus. [V] V1-V3 without
deficits to light touch bilaterally. [VII] Normal forced eyelid
closure bilaterally, left lower face paresis with volitional
smile (minimal movement). [VIII] Hearing intact to finger rub
bilaterally. [IX, X] Palate elevation symmetric. [XI]
SCM/Trapezius strength ___ bilaterally. [XII] Tongue midline.
- Motor - Normal bulk and tone. Left arm pronation and drift,
not
to the bed. No tremor or asterixis. No myoclonus.
=[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[___]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] [L5]
L 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5
- Sensory - No deficits to light touch or temperature
bilaterally. Denies length-dependent sensory gradient.
Diminished
proprioception in both first toes bilaterally. Extinction to
double simultaneous light touch stimulation in the left arm and
leg. Diminished point localization in the left arm compared to
the right.
- Reflexes
=[Bic] [Tri] [___] [Quad] [Gastroc]
L 2 2 2 1 1
R 2 2 2 1 1
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose or heel-shin
testing. Good speed and intact cadence with rapid alternating
movements.
- Gait - Deferred in setting of Code Stroke.
DISCHARGE EXAM:
General: well appearing, awake, comfortable
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity
Cardiovascular: RRR, no M/R/G
Pulmonary: Equal air entry bilaterally, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema, palpable radial/dorsalis pedis
pulses
Skin: No rashes or lesions, but dry hairless lower legs
(half-way
down)
Neurologic Examination:
- Mental Status - Awake, oriented x 3. Attention to
examiner easily attained and maintained. Concentration
maintained
when recalling months backwards. Recalls a coherent history.
Structure of speech demonstrates fluency with full sentences,
intact repetition, and intact verbal comprehension. Content of
speech demonstrates intact naming (high and low frequency) and
no
paraphasias. Normal reading. Normal prosody. Mild dysarthria for
mouth sounds. No apraxia. No left-right agnosia.
- Cranial Nerves - [II] PERRL 3->1.5 brisk. VF full to number
counting. [III, IV, VI] EOMI, no nystagmus. [V] V1-V3 without
deficits to light touch bilaterally. [VII] Normal forced eyelid
closure bilaterally, left lower face paresis with volitional
smile (minimal movement). [VIII] Hearing intact to finger rub
bilaterally. [IX, X] Palate elevation symmetric. [XI]
SCM/Trapezius strength ___ bilaterally. [XII] Tongue midline.
- Motor - Normal bulk and tone. Left arm pronation and drift,
not
to the bed. No tremor or asterixis. No myoclonus.
=[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[___]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] [L5]
L 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5
-full strength as documented above when patient asked to pay
attention to his left side.
- Sensory - No deficits to light touch or temperature
bilaterally. Denies length-dependent sensory gradient.
Diminished
proprioception in both first toes bilaterally. Extinction to
double simultaneous light touch stimulation in the left arm and
leg. Diminished point localization in the left arm compared to
the right.
- Reflexes
=[Bic] [Tri] [___] [Quad] [Gastroc]
L 2 2 2 1 1
R 2 2 2 1 1
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose or heel-shin
testing. Good speed and intact cadence with rapid alternating
movements.
- Gait - Walking slowly without assistance
Pertinent Results:
___ 08:52AM BLOOD WBC-7.0 RBC-5.72 Hgb-15.1 Hct-44.8
MCV-78* MCH-26.4* MCHC-33.7 RDW-13.1 Plt ___
___ 08:52AM BLOOD ___ PTT-35.1 ___
___ 08:52AM BLOOD ___ 05:30AM BLOOD Glucose-145* UreaN-12 Creat-1.0 Na-138
K-3.6 Cl-101 HCO3-29 AnGap-12
___ 05:30AM BLOOD CK(CPK)-132
___ 08:52AM BLOOD cTropnT-<0.01
___ 05:30AM BLOOD CK-MB-1 cTropnT-<0.01
___ 08:52AM BLOOD Calcium-9.1 Phos-3.0 Mg-2.0
___ 05:30AM BLOOD Calcium-9.1 Phos-4.5 Mg-2.3 Cholest-188
___ 03:50PM BLOOD %HbA1c-9.7* eAG-232*
___ 05:30AM BLOOD Triglyc-95 HDL-47 CHOL/HD-4.0 LDLcalc-122
___ 08:52AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:05AM BLOOD Glucose-210* Lactate-1.6 Na-142 K-4.1
Cl-99 calHCO3-28
IMAGING:
CTA HEAD/NECK:
IMPRESSION: Abnormal hypodensity, consistent with infarction
involving the right caudate and lentiform nuclei. Note is made
of a corresponding severe focal filling defect, presumably an
embolus, in the mid portion of the right M1 segment.
TTE w BUBBLE:
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). Right ventricular chamber size and free wall motion are
normal. The diameters of aorta at the sinus, ascending and arch
levels are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: No intracardiac source of thromboembolism
identified.
MRI HEAD:
IMPRESSION:
Acute infarct in the right basal ganglia region. No hemorrhage.
Brief Hospital Course:
___ RHM p/w left facial droop and left arm weakness, ___
reveals subtle edema in the right basal ganglia with effacement
of the frontal horn of the right lateral ventricle, CTA shows
narrowing of the R M1. The stroke was likely due to intracranial
atherosclerosis. Patient had q4h neurochecks on the floor. He
received aspirin 325mg daily, patient's home lisinopril was
held. His home simvastatin to 40mg daily. Patient was placed on
an insulin sliding scale while in hospital and his home
glipizide was held. Patient's hgbA1C was 9.7%. The diabetes
specialists from ___ recommended starting lantus. Patient was
instructed to follow closely with his PCP after discharge from
rehab. Patient received heparin SC for DVT prophylaxis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. GlipiZIDE XL 10 mg PO DAILY
3. Simvastatin 10 mg PO DAILY
Discharge Medications:
1. Simvastatin 40 mg PO DAILY
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
3. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus] 100 unit/mL 0.1 mL 10 Units before
BED; Disp #*30 Syringe Refills:*0
4. Lisinopril 20 mg PO DAILY
5. GlipiZIDE XL 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute Ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were hospitalized due to symptoms of L-sided weakness
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
-high cholesterol
-high blood pressure
-diabetes
We are changing your medications as follows:
INCREASING simvastatin to 10mg daily
INCREASING aspirin to 325mg daily
ADDING 10U Lanuts QPM
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:
___
|
10140907-DS-13 | 10,140,907 | 23,984,083 | DS | 13 | 2133-04-26 00:00:00 | 2133-04-26 13:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
worsening L sided weakness
Major Surgical or Invasive Procedure:
Nil
History of Present Illness:
___ who presents with left hemibody weakness (face arm> leg)
with left sided neglect on a background of recent admission for
Right basal ganglial ischemic infarct, DM, HTN, HL.
Please see code stroke admission note from ___ for further
details. Briefly he is a ___ with HTN, HL, DM who presented
with left hemibody weakness of unclear duration and found to
have a right basal ganglia infarct. He was not a candidate for
thrombolysis given the unclear duration. He was started on
aspirin and statin and discharged to rehab on ___.
Last night he did not get much in the way of sleep because of a
persistent headache that he has had since discharge. He then
participated in ___ for some lengthy duration this morning. At
1pm, his wife went to visit him and noted, while he attempted to
get to the bathroom, that his left side appeared weaker and that
he was having trouble walking and he was therefore transfered to
the ED at ___.
A code stroke was called. His initial vitals were : 97.8 75
128/69 16 97% RA
Past Medical History:
Hypertension
Hyperlipidemia - LDL 122 in ___
Type 2 DM - A1C 9.6% in ___
R basal ganglia ischemic infarct, thought to be due to R MCA M1
stenosis
Social History:
___
Family History:
There's no family history of stroke, myocardial infarction, deep
vein thrombosis, pulmonary embolism, recurrent miscarriages, or
rheumatologic disease. His mother had diabetes and hypertension.
There's otherwise no history of neurologic disease.
Physical Exam:
ADMISSION EXAM:
General exam:
97.8 75 128/69 16 97% RA
NAD, drowsy, lying in bed
HEENT: supple, no pain
CV: RRR
Lungs: CTA
Abd: soft, nd nt
Extremities: wwp
___ Stroke Scale score was 6:
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 2
5a. Motor arm, left: 2
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: 1
11. Extinction and Neglect: 1
-Mental Status: Drowsy but easily arousable with voice, oriented
x 3.
Able to relate history without difficulty.
Language is fluent with intact repetition and comprehension.
There were no paraphasic errors.
Able to read without difficulty.
Speech with notable labial dysarthria
Able to follow both midline and appendicular commands.
The pt. had good knowledge of current events including the
activities of the day prior to his presentation.
There was significant left sided neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 3mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades. Able to
track across the midline and to saccade over to each side in
conjugate fashion
V: Facial sensation intact to light touch.
VII: profound facial droop on the left, facial musculature
asymmetric.
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 on the
right, difficult to assess on the left No adventitious
movements, such as tremor, noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 3* 3* 3* 3* 3* 3* 4* 4+ 4 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
** strength exam is limited by drowsiness and neglect
-Sensory: Unclear sensory deficit on the left given the degree
of neglect of that side No deficits to light touch, pinprick,
cold sensation, vibratory sense, proprioception on the right.
Extinguishes to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor on the left and mute on the left.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS (although difficult to assess on the
left)
-Gait: deferred
====================================
DISCHARGE EXAMINATION:
Mr. ___ had SBPs in the 130s-140s range. His blood
sugars were in the 200s, which required frequent uptitrations in
his daily lantus dose. On examination, he can appear sleepy and
uninvolved, but his quite responsive. His eyelids tend to be
droopy. His language functions are normal. He extinguishes to
DSS on the left. PERRL, with full EOMs. Left sided upper and
lower facial weakness with a tongue that protrudes leftward.
Left facial weakness. Slowness of movements on the left arm and
leg. Notable weakness in the left deltoid (4-) and left wrist
extensors/finger extensors. Left ankle clonus. Left hamstring
and TA weakness (4-).
Pertinent Results:
ADMISSION LABS:
___ 03:34PM BLOOD WBC-7.1 RBC-6.43* Hgb-16.9 Hct-51.1
MCV-79* MCH-26.3* MCHC-33.1 RDW-13.3 Plt ___
___ 03:34PM BLOOD ___ PTT-41.5* ___
___ 03:34PM BLOOD UreaN-21*
___ 03:51PM BLOOD Creat-0.9
================================
IMAGING:
CTA/CT PERFUSION OF HEAD ___:
1. Perfusion deficit consistent with right MCA territory infarct
which is increased in size compared to the prior diffusion
weighted imaging. Unchanged intraluminal filling defect in the
right MCA.
2. Small hyperdensity in the right caudate head in the region of
prior infarct could possibly represent a small area of
hemorrhage.
MRI ___:
Interval increase in the extent of right middle cerebral
arterial distribution embolic infarction as above, as well as
interval development of right basal ganglionic hemorrhagic
transformation.
CT head ___:
Subacute infarct centered in the right basal ganglia with
subacute hemorrhagic transformation. More recent acute to early
subacute infarcts in the right frontal and parietal lobes. No
significant change compared to one day earlier.
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
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
x() Yes - () No
4. LDL documented? (x) Yes (LDL = ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
==============================================
NEURO ICU COURSE ___
Mr. ___ is a ___ yo RH man with history of HTN, HLD,
T2 DM and recent hospitalization for R basal ganglia infarct in
setting of focal R M1 stenosis who presented with worsening L
sided weakness from rehab and found to have enlargement of
stroke.He was initially admitted to neuro ICU for frequent
neurochecks. His MRI showed interval worsening of R MCA infarct
with hemorrhagic conversion in the R basal ganglia. Given the
hemorrhage, aspirin was held briefly and and restarted when his
repeat head CT showed stable hemorrhagic conversion. His blood
pressure was allowed to autoregulate with goal SBP 140-180 and
he was given IVF prn to keep at goal. He was transferred to
neurology ___ after 2 days of monitoring in the ICU.
His modifiable risk factors were checked during previous
admission (___), so he was continued on insulin sliding
scale and his simvastatin was changed to atorvastatin 80 mg
daily. His examination remained stable throughout his course and
his HOB restrictions were liberalized. We provided supportive
relief with insulin. He was switched from aspirin to aggrenox to
provide some vasodilatation effects. He initially suffered from
some right sided headaches, but this improved over time. A rehab
bed was identified and he was discharged to rehab. His wife was
kept informed throughout his hospitalizations.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Simvastatin 40 mg PO DAILY
3. GlipiZIDE XL 10 mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Atorvastatin 80 mg PO DAILY
2. Dipyridamole-Aspirin 1 CAP PO BID
3. Glargine 14 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Heparin 5000 UNIT SC TID
5. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN ___
headache
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right MCA stenosis
Right MCA acute ischemic infarction
Discharge Condition:
Mental Status: Clear and coherent, follows commands in ___
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear ___,
You were hospitalized at the Neurology Wards of ___
because of some worsening weakness on the left side that you
experienced. We checked an MRI of your brain, and we discovered
that your stroke had enlarged. As you know, a blood vessel in
the right side of your brain is quite "stenosed" (blocked), and
with relatively lower blood pressures, blood flow through that
vessel had been impaired.
You were hospitalized first in the ICU and then transferred
to the ___. You received IV fluids and your bed was kept flat
to maintain flow through that artery.
We discontinued your hypertension medication and have
switched you from aspirin to AGGRENOX (which also contains some
aspirin). We also increased your STATIN medication (for high
cholesterol) to ATORVASTATIN.
With continued rehabilitation, we expect improvement in the
strength of your left side. It is important that you follow up
with the appointments noted below, and do not hesitate to
contact us with questions or comments.
It was a pleasure caring for you.
Followup Instructions:
___
|
10141031-DS-15 | 10,141,031 | 25,541,845 | DS | 15 | 2148-05-08 00:00:00 | 2148-05-08 19:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with pmhx HTN, obesity, stage 3 CKD, arrives via EMS for
evaluation of an episode of lightheadedness, dizziness,
weakness, and fall with possible loss of consciousness.
He states that he did not feel well this morning when he went to
work at approximately 0500. He reports that he felt dizziness,
lightheadedness, and weakness throughout most of the morning.
His job requires him to stand for long periods of time but due
to his symptoms he needed to sit down every few minutes to take
a rest. At around 0800, while he was walking at work he noticed
quickly worsening of his lightheadedness and dizziness as well
as a cold sweat and mild nausea. As he was walking, he fell and
thinks that he lost consciousness. He said that he hit his head
when he fell. Nearby coworkers saw him fall and called EMS. He
states that he continued to feel dizzy and lightheaded for about
20 minutes after his fall and started to feel better en route to
the hospital. He denies palpitations prior to the fall and
denies any loss of bowel/bladder function after the fall. He
denies confusion following the fall.
He denies any recent chest pain, shortness of breath, abdominal
pain, fever, vomiting, changes in bowel or bladder function
Also of note, ___ reports that he did not have breakfast
this morning and says that he did have some water but is not
sure how much. He also notes back pain (chronic) for which he
took cyclobenzaprine.
Additionally, he complains of worsening RLE wound, has a history
of pyoderma gangernosum ulcerating lesion to the RLE - in ___
had been admitted for cellulitis overlying the ulcer and had
been followed by Dr. ___. since then concern for pyoderma
gangrenosum and has been treated with oral steroids for approx.
2 months - he does not feel that it has improved with steroids.
In the ED, initial VS were 96.0, 70, 86/59, 20, 96% RA
Exam notable for bilateral 2+ pitting edema, with 6cm ulcerating
wound to the posterior right calf, exposed underlying tissue
with yellow exudative drainage. No abnormalities noted on
cardiopulmonary exam.
Labs showed lactate 2.2, trop neg, K+ 3.1, BUN/Cr 32/1.4, ALT 57
AST 42, Hgb 12.0, WBC 5.3 (78.3% PMNs), PTT 22.1
Imaging showed no evidence of PE or acute aortic abnormality on
CT Abd/pelvis. CXR demonstrated possible mildly enlarged heart
but could be due to portable technique.
EKG with mild T wave flattening in lateral leads suggestive of
possible ischemia. No ST segment changes that would be
consistent with ACS. No notable arrhythmias.
Received IV morphine sulfate, magnesium sulfate, acetaminophen,
IVFs (1L normal saline as well as D5NS + 40meQ KCl 250ml/hr)
Vascular surgery was consulted for chronic right calf wound: No
evidence of cellulitis and the wound base appears clean with
good granulation tissue. Recommend continued local wound care
with compression and elevation.
Decision was made to admit to medicine for further management.
Transfer VS were 97.9 99 126/74 20 98%RA
Past Medical History:
morbid obesity, hypertension,
transaminitis, varicose veins, sleep apnea, hld, hyperglycemia
(prediabetes), superficial thrombophlebitis, ulcer of right calf
Social History:
___
Family History:
NA
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 97.9 102/71 81 18 98%RA Orthostatics: sitting BP 113/74 HR
69, standing BP 93/60 HR 90
GENERAL: lying comfortably in bed, NAD, morbidly obese
HEENT: AT/NC, EOMI, PERRL
NECK: no LAD, no JVD appreciated (possibly limited by body
habitus)
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft, nontender, +BS, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: 2+ pitting edema of lower extremities bilaterally
extending to ___, brawny discoloration of lower extremities
in edematous region, bandages of right lower calf appear clean
and dry.
PULSES: 2+ DP pulses bilaterally
NEURO: CN ___ intact
SKIN: warm and well perfused, lower extremities as above
DISCHARGE PHYSICAL EXAM:
VS- 98.3 ___ 20 ___ RA
Orthostatic Vitals: Supine 146/83, Sit 153/90, Stand 146/87
GENERAL: lying comfortably in bed, NAD, morbidly obese
HEENT: AT/NC, EOMI, PERRL
NECK: no LAD, no JVD appreciated (possibly limited by body
habitus)
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft, nontender, +BS, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: 2+ pitting edema of lower extremities bilaterally
extending to ___, brawny discoloration of lower extremities
in edematous region, bandages of right lower calf appear clean
and dry.
PULSES: 2+ DP pulses bilaterally
NEURO: CN ___ intact
SKIN: warm and well perfused, lower extremities as above
Pertinent Results:
==============
ADMISSION LABS
==============
___ 09:00AM BLOOD ___
___ Plt ___
___ 09:00AM BLOOD ___
___ Im ___
___
___ 09:00AM BLOOD ___ ___
___ 09:00AM BLOOD Plt ___
___ 06:45PM BLOOD Ret ___ Abs ___
___ 09:00AM BLOOD ___
___
___ 06:45PM BLOOD ___
___
___ 06:45PM BLOOD LD(LDH)-337*
___ 09:00AM BLOOD ___
___ 09:00AM BLOOD ___
___ 06:45PM BLOOD cTropnT-<0.01
___ 09:00AM BLOOD cTropnT-<0.01
___ 06:45PM BLOOD ___
___ 09:00AM BLOOD ___
___ 06:45PM BLOOD ___
___ 06:45PM BLOOD ___
___ 06:45PM BLOOD ___
___ 09:00AM BLOOD ___
___
___ 09:22AM BLOOD ___
___ 09:52PM BLOOD ___
==============
MICROBIOLOGY
==============
___ 11:20 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 9:10 am BLOOD CULTURE
Blood Culture, Routine (Pending):
==============
IMAGING
==============
___ CXR:
FINDINGS:
There is no focal consolidation, pleural effusion or
pneumothorax. No
evidence of pulmonary edema. Heart size appears mildly
enlarged, although
this may be exaggerated by portable technique. No acute osseous
abnormalities
are identified.
IMPRESSION:
Clear lungs. Heart size appears mildly enlarged, although this
may be
exaggerated by portable technique.
___ CTA CHEST/ABDOMEN:
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Nonspecific prominent left lower paratracheal node measuring
14 mm,
possibly reactive. 3. 4 mm right lower lobe pulmonary nodule,
with a possible second 3 mm right upper lobe nodule. Per
___ criteria, no ___ needed in ___ patients.
For high risk patients, recommend ___ at 12 months and if
no change, no further imaging needed.
4. Moderate hiatal hernia.
RECOMMENDATION(S): In the case of nodule size <= 4 mm: No
___ needed in ___ patients. For high risk patients,
recommend ___ at 12 months and if no change, no further
imaging needed.
==============
DISCHARGE LABS
==============
___ 07:35AM BLOOD ___
___ Plt ___
___ 07:35AM BLOOD Plt ___
___ 07:35AM BLOOD ___ ___
___ 07:35AM BLOOD ___
___
___ 07:35AM BLOOD ___
Brief Hospital Course:
#Syncope: ___ with pmhx HTN, obesity, stage 3 CKD, presents
following likely syncopal episode, in the setting of
lightheadedness, dizziness, weakness, cold sweat and possible
decreased caloric/fluid intake. Most concerning for vasovagal
syncope or mixed vasovagal/orthostatic syncope with cardiac
etiology less likely. EKG did not exhibit arrhythmia or ischemic
changes. Trops negative x2. SBP in ___ in ED. No events on tele
overnight. Orthostatics were positive on the floor, so ___
was given IVF and had his diuretics held. He was asymptomatic
the day of discharge with negative orthostatics. He will hold
his Lasix for 2 days following discharge and will follow up with
his PCP ___ weeks.
#RLE wound: ___ had a chronic wound on the right calf since
___. Per vascular surgery, there was no evidence or cellulitis
and the wound base was clean with good granulation tissue.
___ believed this wound is a manifestation of pyoderma
gangrenosum. He had previously tried antibiotics without
effect. He was currently taking prednisone but does not believe
it is helping. Per chart review, diagnosis of pyoderma
gangrenosum may not be substantiated. Per vascular he should
follow up with ___.
#Anemia: Hgb on admission 12.0 (baseline approximately 14) with
MCV 101 with 4% reticulocytes (RPI 3.3%--adequate response).
Possible causes include B12 deficiency, folate deficiency,
hypothyroidism, reticulocytosis, alcohol use. B12, folate, TSH
were normal this admission. Hemolysis should also be considered
given anemia with borderline ___ MCV and adequate
reticulocyte response
#CKD: ___ has stage 3 CKD with Cr range over the past 4
months of ___ per Atrius records. Per BI records, previous
Cr baseline of 0.8. Presented with Cr 1.4 in the ED.
-Held home Lasix
#Possible hyperglycemia: Prior hyperglycemia, morbid obesity,
poorly healing lower extremity may all be consistent with
diabetes although ___ has never been formally diagnosed.
HbA1c was 5.5.
TRANSITIONAL ISSUES:
MEDICATIONS HELD: Lasix 40 mg PO daily (to resume ___
- Consider rechecking blood pressure/orthostatics at next PCP
visit as ___ came in hypotensive and with positive
orthostatics
- Discharge H/H 11.6/___.1 w/ an MCV of 103. Folate, B12, and TSH
wnl. Consider rechecking CBC at next PCP visit
- ___ to follow up with ___ wound clinic for management
of his chronic wound. Per ___ vascular surgery, no follow up
here is necessary.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 25 mg PO BID
2. Chlorthalidone 50 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. PredniSONE 20 mg PO BID
5. Cyclobenzaprine 10 mg PO TID:PRN Muscle spasm
6. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate
7. Furosemide 40 mg PO ONCE
Discharge Medications:
1. Carvedilol 25 mg PO BID
2. Chlorthalidone 50 mg PO DAILY
3. Cyclobenzaprine 10 mg PO TID:PRN Muscle spasm
4. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate
5. Lisinopril 40 mg PO DAILY
6. PredniSONE 20 mg PO BID
7. HELD- Furosemide 40 mg PO ONCE This medication was held. Do
not restart Furosemide until ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Orthostatic hypotension
Macrocytic anemia
Stage 3 chronic kidney disease
SECONDARY DIAGNOSES:
Chronic venous ulcer
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 passed out while
at work. You were evaluated for concerning causes of this
episode but none were found. We believe that you were dehydrated
and had a low blood pressure causing you to briefly lose
consciousness and fall to the floor. All of your other
nueurological and cardiac testing did not reveal any abnormality
which we could attribute to this event.
When you leave the hospital, it is important for you to take
your medications as directed. You should stop taking your Lasix
for 2 days when you get home (restart on ___. You should also
make an appointment to follow up with your PCP ___ 2 weeks of
discharge.
All our best,
Your ___ Care Team
Followup Instructions:
___
|
10141035-DS-5 | 10,141,035 | 24,374,681 | DS | 5 | 2144-11-22 00:00:00 | 2144-11-23 20:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
___ transferred from ___ after workup for weakness,
confusion, found to have renal failure, UTI (Creat 12.53, K6.4
prior to transfer).(Received ceftriaxone 1gm, 2L NS, insulin,
D50, calcium gluconate, lasix 10mg prior to transfer). Baseline
Cr 1.39 in ___.
Per family pt confused, weak, unexplained bruising, taken to ___
office with
ICU HPI:
==========
c/o weakness for unknown period of time, has lost 12lbs since
___. Was tachycardic in office. Noted to have bruising over
body. She cannot give answer as to how she obtained bruises. She
is confused, cannot recall why she went to ___ office this
morning, does not report complaints.
In the ED, Rectal temp 100.4. Aox2. scattered bruising. clonus
in hands, feet. foley with UO output.
CT head at ___: There is no evidence of acute
intracranial hemorrhage, edema, mass effect, or large
territorial infarction.
CXR at ___: FINDINGS: The lungs are well inflated and
free of consolidation. The heart is not enlarged. The osseous
structures are normal for age. Monitor leads overlie the chest.
IMPRESSION: Lungs clear.
In ___ ED, was seen by Renal. They recommend no current need
for emergent HD tonight but will require it tomorrow. It is
unclear the etiology of her renal failure but obstruction can
not be ruled out. she is making urine, she is not hypervolemic
and she is mentating, there is no current need for emergent
hemodialysis tonight, though she will almost certainly require
it in the coming days.
INTERNAL MEDICINE HPI:
======================
___ y/o F hx of recurrent UTI, HTN, breast cancer transferred
from OSH after found with altered mental status at doctor
appointment only 3 days after her husband moved out to go to
assisted living facility. Found to have bruises at admission,
severe hyperkalemia and elevated creatinine, likely ___
azotemia in context of possible rhabdomyolysis, treated at
___ with calcium gluconate and fluids. Now improving, and
ready for transfer to the floor. No SOB/CP/fever/chills.
Metavision vitals:98.4, 125/47, pulse 100, rr12, 100% O2
Past Medical History:
breast ca ___, stage III dx ___, osteoporosis, HLD, HTN,
recurrent UTI
Social History:
___
Family History:
No known family hx of renal disease.
Physical Exam:
ADMISSION PHYSICAL EXAM (ICU):
========================
Vitals- T:97.2 oral BP:105/41 P:56 R:16 18 O2:100
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: expiratory wheezes throught lung field, no rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, ___, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no break down
NEURO: PERRL EOMI intact extremities x4 grossly intact AA0x2
"hospital and full name"
ADMISSION PHYSICAL EXAM (INTERNAL MEDICINE):
================================
Vitals: 98.4, hr100, 125/47, rr12, 100% O2
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, EOMI, PERRLA, oropharynx clear.
Periorbital eye bruise.
NECK: supple, JVP not elevated, no LAD
LUNGS: CTAB, no rales, rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, ___, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Right arm bruise.
SKIN: No visible rashes or skin breakdown
GU: Foley in place.
NEURO: Left facial droop (chronic). FROM x 4, AA0x3 (name, date,
hospital). Does not know reason for admission, or remember
recent fall.
DISCHARGE PHYSICAL EXAM (INTERNAL MEDICINE):
================================
VITALS: 99.0, 108/47, 88 pulse, 16 rr, 99% on RA
GENERAL: Alert, oriented, no acute distress. Very pleasant
HEENT: Sclera anicteric, MMM, oropharynx clear.
NECK: supple, JVP not elevated
LUNGS: CTAB, no rales, rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, ___, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Right arm bruise.
SKIN: No visible rashes or skin breakdown
GU: Foley in place.
NEURO: Left facial droop (chronic). FROM x 4, AAOx3, unable to
recount the rest of her hospital course or exact reason for
admission.
Pertinent Results:
ON ADMISSION:
============
___ 06:45PM BLOOD ___
___ Plt ___
___ 06:45PM BLOOD ___
___
___ 06:45PM BLOOD Plt ___
___ 10:40PM BLOOD ___ ___
___ 06:45PM BLOOD ___
___
___ 06:45PM BLOOD ___
___ 06:45PM BLOOD ___
___ 10:40PM BLOOD ___
___ 06:45PM BLOOD ___
___ 10:40PM BLOOD ___
___ 10:40PM BLOOD ___
___ 06:45PM BLOOD ___
___ 09:55PM BLOOD ___ U
___ 11:31PM BLOOD ___
___ Base XS--14 ___ INTUBA
___ 06:54PM BLOOD ___
___ 09:55PM BLOOD ___
___ 09:55PM BLOOD ___
___ 08:30PM URINE ___ WBC->182* ___
___
___ 08:30PM URINE ___
___
___ 08:30PM URINE ___ Sp ___
___ 08:30PM URINE ___
___
___ 08:30PM URINE ___
___ 08:30PM URINE ___
___
PERTINENT LABS DURING HOSPITALIZATION:
============================
___ 02:48AM BLOOD ___
___ Plt ___
___ 05:31AM BLOOD ___
___ Plt ___
___ 05:15AM BLOOD ___
___ Plt ___
___ 03:00PM BLOOD ___
___
___ 05:31AM BLOOD ___
___
___ 05:15AM BLOOD ___
___
___ 05:15AM BLOOD ___
___
MICROBIOLOGY:
==========
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
MRSA SCREEN - NEGATIVE
IMAGING:
=======
___: RENAL ULTRASOUND
The right kidney measures 9.5 cm. The left kidney measures 9.9
cm. There is no
hydronephrosis. No cyst or stone or suspicious solid mass is
seen in either
kidney. Normal cortical echogenicity and corticomedullary
differentiation are
seen bilaterally. No perinephric fluid collection is
identified.
The bladder is entirely filled with a large echogenic mass which
measures 6.8
x 8.3 x 5.6 cm. Arterial and venous flow is identified within
this mass on
color and spectral waveform Doppler. The appearance is
consistent with
urothelial carcinoma. A Foley catheter balloon is also noted
within the
bladder adjacent to the mass.
IMPRESSION:
1. Large vascularized mass filling the urinary bladder most
consistent with a
urothelial carcinoma.
2. Unremarkable appearance of the kidneys.
___: CHEST XRAY
The lung volumes are high an show evidence of overinflation.
Bilateral apical
symmetrical thickening. No evidence of lung nodules or masses.
No pneumonia,
no pulmonary edema. Normal size of the cardiac silhouette.
Brief Hospital Course:
___ year old female hx of HTN, breast cancer, recurrent UTI, who
presented to ___ with UTI, confusion, ___ with Cr 12 and
K 6.4 with peaking of T waves after being found disoriented,
consistent with rhabdomyolysis and urosepsis. She was
transferred to ___ for further management, incidentally found
to have a bladder mass that may be malignant and is now
significantly improved clinically.
#Severe sepsis due to UTI: Fever and tachycardia at presentation
with creatinine elevated from baseline. Patient was also
hypotensive at presentation, and responded to fluid
resuscitation. Urinalysis was positive for infection, and she
was covered empirically with ceftriaxone until her urine culture
showed ___ E. coli. Her hemodynamics improved, her
leukocytosis was downtrending, and she was transitioned to
ciprofloxacin PO for continued UTI treatment. She was
transferred to the floor in improved condition. On the internal
medicine service, Ms. ___ renal function continued to
improve and she was transitioned from ciprofloxacin to oral
ampicillin (on ___ to treat her enterococcal infection.
She continued as an outpatient to fulfill a total course of 7
days of ampicillin to be completed on ___.
#Acute on chronic kidney injury: Cr was 10.3 at presentation,
significantly elevated from baseline of 1.8 in ___.
Initially thought to be ___ from severe sepsis given Cr
improved with fluids. However, her renal ultrasound on ___
showed a large vascularized mass filling the bladder concerning
for urothelial carcinoma, so there was likely also an element of
obstructive uropathy causing her renal insufficiency. She was
evaluated by nephrology and felt to have no emergent dialysis
needs. After transfer to internal medicine service, her
creatinine continued to improve to 1.3 at time of discharge.
#Renal Mass
Seen on renal ultrasound: "Large vascularized mass filling the
urinary bladder most consistent with a urothelial carcinoma." It
was recommended that she follow up as an outpatient with
urology. Patient was reminded daily of importance of this
followup and that mass may represent cancer. Given her
enterococcal infection, the mass may play an obstructive role
(albeit intermittent) and can increase her risk of UTI. An
appointment with urology was arranged on discharge.
# Anemia
Trace guaiac positivity of stools in the ICU was concerning for
GI bleed, however the patient's H/H slowly improved as the acute
inflammation of urosepsis and rhabdomyolysis subsided. Remained
asymptomatic of anemia and RBC counts remained stable. Iron labs
indicated likely anemia of chronic disease/inflammation. As
outpatient should continue to trend hemoglobin and determine if
any intermittent cause of bleeding.
#Hyperlipidemia - Known issue, patient not interested in
medications for this.
#Hypertension - Stable. Hypotensive intermittently during
hospitalization and not on ___ in the hospital.
Can continue ___ as outpatient.
#Osteoporosis - Stable. Continue management as outpatient.
Transitional Issues:
====================
- Follow up with Urology for further evaluation and management
of bladder mass concerning for cancer
- f/u with PCP
- ___ twice weekly electrolyte checks including phosphate,
replete electrolytes as needed
- Continue antibiotics for full 7 day course (started
___, ends on ___.
- code status: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Viactiv ___ K) unknown mg oral QD
3. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
4. ___ mg oral QD
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Ampicillin 500 mg PO Q8H
RX *ampicillin 500 mg 1 capsule(s) by mouth three times a day
Disp #*9 Capsule Refills:*0
3. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
4. ___ mg ORAL QD
5. Viactiv ___ K) 0 mg ORAL QD
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Rhabdomyolysis
Acute renal failure
Hyperkalemia
Urosepsis
Anemia
Hypernatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You came to ___ due to very
high potassium levels in your blood along with failure of your
kidneys. You spent time in the intensive care unit, where your
kidneys recovered, and your potassium levels returned to normal.
You noted that your home environment has not recently been a
safe one, and you were seen by the social workers to further
discuss this. The physical therapists worked with you and you
continued to grow stronger in the hospital. They recommended
that you go to a rehabilitation facility before going home. In
addition, it will be important to follow up with your primary
care physician after leaving the hospital.
In addition, one of your scans shows a bladder mass that may
represent cancer. We have discussed this with you, and recommend
that you follow up with a urologist.
It has been a pleasure caring for you here at ___
___, and we wish you all the best!
Kind regards,
Your ___ Team
Followup Instructions:
___
|
10141035-DS-6 | 10,141,035 | 24,588,863 | DS | 6 | 2144-12-19 00:00:00 | 2144-12-19 22:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Fever/Delirium
Major Surgical or Invasive Procedure:
TURBT STAGE I (___)
PERCUTANEOUS RIGHT NEPHROSTOMY TUBE PLACEMENT (___)
TURBT STAGE II (___)
TURBT STAGE III (___)
History of Present Illness:
___ w/ recently diagnosed urothelial carcinoma, recurrent UTI,
h/o breast cancer, htn/hl, presented from her assisted living
facility w/ sepsis.
Pt is referred from ___ to ___ for evaluation
increasing WBC to 18K today w/ left shift, acidosis in
bicarb=20, and worsening renal function of Cr to 1.9 (baseline
1.1). Patient does report throbbing w/ urinating and sister
reports grimacing w/ urinating. She denies any other symptoms
but is slightly confused, stating she is in the facility for the
UTI and that she ambulates, though she is wheelchair bound. No
associated f/c, n/v/d/c, cp, sob, or focal weakness. Recent hx
of pyuria w/ negative culture at facility. Foley insertion was
attempted at her facility but nurses were unable to inflate the
balloon.
In the ED initial vitals were: 98.3 88 108/45 18 99%
- Labs were significant for WBC 14.3 Hct 21 (baseline 22 - 25),
Cr 2.1 (baseline 1.2)
UA showed large leuk, neg nitrite, many bac, WBC > 182
- Patient was given Piperacillin-Tazobactam 4.5 g IV ONCE
Vitals prior to transfer: 98.4 106 113/57 22 99% RA
On the floor, pt denies f/c/n/v, back pain.
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:
breast ca ___, stage III dx ___, osteoporosis, HLD, HTN,
recurrent UTI
Social History:
___
Family History:
No known family hx of renal disease. Pt has no known history of
bladder malignancies. There is a history of
hypertension/hyperlipidemia in her family.
Physical Exam:
ADMISSION PHYSICAL EXAM
PHYSICAL EXAM:
Vitals - 98 126/49 98 18 100RA
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 anteriorly, no wheezes, rales, rhonchi, breathing
comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
suprapubic tendernessno rebound/guarding, no hepatosplenomegaly
BACK: no CVA tenderness
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
Vitals: T:98.9 BP:137/59 HR:99 RR:17 O2:95 on RA
GENERAL: NAD; A+Ox3 but unclear of overall functionality
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: mild crackles in the bases bilaterally; no wheezes, rales,
rhonchi, breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, mild suprapubic tenderness; no
rebound/guarding, no hepatosplenomegaly
BACK: no CVA tenderness
EXTREMITIES: ___ edema in the patients upper extremities L>R;
no cyanosis, clubbing, moving all 4 extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
___ 07:10AM GLUCOSE-92 UREA N-59* CREAT-2.1* SODIUM-139
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-21* ANION GAP-19
___ 07:10AM ALT(SGPT)-27 AST(SGOT)-24 LD(LDH)-261* ALK
PHOS-93 TOT BILI-0.2
___ 07:10AM ALBUMIN-2.5* CALCIUM-8.0* PHOSPHATE-3.6#
MAGNESIUM-1.7
___ 07:10AM WBC-16.4* RBC-2.4* HGB-7.2* HCT-22.8* MCV-95
MCH-30.0 MCHC-31.8 RDW-32.5*
___ 07:10AM PLT SMR-NORMAL PLT COUNT-399
___ 12:20AM URINE HOURS-RANDOM
___ 12:20AM URINE UHOLD-HOLD
___ 12:20AM URINE COLOR-Red APPEAR-Cloudy SP ___
___ 12:20AM URINE BLOOD-LG NITRITE-NEG PROTEIN-300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 12:20AM URINE RBC->182* WBC->182* BACTERIA-MANY
YEAST-NONE EPI-0
___ 12:20AM URINE WBCCLUMP-MANY MUCOUS-RARE
___ 10:25PM LACTATE-1.2
___ 10:20PM GLUCOSE-115* UREA N-63* CREAT-2.1*
SODIUM-132* POTASSIUM-4.8 CHLORIDE-101 TOTAL CO2-23 ANION GAP-13
___ 10:20PM WBC-14.3* RBC-2.34* HGB-7.0* HCT-21.9* MCV-94
MCH-29.8 MCHC-31.8 RDW-14.9
___ 10:20PM NEUTS-85.3* LYMPHS-9.6* MONOS-3.6 EOS-1.0
BASOS-0.5
___ 10:20PM PLT SMR-HIGH PLT COUNT-465*#
MICRO/CYTOLOGY AND STUDIES
MICRO:
UCx: ___, pan-sensitive E.Coli
BCx: ___, pending x 2
PRIOR MICRO:
UCx: enterococcus (vanc sensitive)
===========================================================
STUDIES:
MRI Pelvis +/- (___):
MRI A/P +/- (___):
- 6.3x7.2x7.3cm avidly enhancing mass arising from the posterior
wall/bladder base of the bladder w/ frondlike configuration
extending into the lumen of the bladder and surrounding layering
non-enhancing debris (likely representing blood products)
- focal areas of loss of the retrovesical fat plan within the
upper uterine segment, concerning for local invasion
- bilateral distal ureters are dilated as they approach the
trigone; no enhancing tumor is seen within the ureters. Mild
prominence of the upper collecting systems bilaterally, left
greater than right, and lack of contrast excretion in to the
collecting systems is indicative of obstruction
- moderate amount of free pelvic fluid within the cul de sac; no
pelvic, retroperitoneal, or inguinal lymphadenopathy is
identified
- small, bilateral pleural effusions as well as diffuse muscular
edema
- no osseous lesions concerning for metastasis
- impression: large bladder mass consistent w/ primary
urothelial neoplasm, most likely transitional cell Ca. While
the majority appears contained within the bladder, there is
concern for local invasion posteriorly with loss of fat plane
between the bladder and the uterus. No distal metastases are
identified. Bilateral renal collecting systems are obstructed
at the UV junctions, without extension of the tumor into the
ureters.
Urine Cytology (___): Consistent with urothelial carcinoma
Renal U/S (___):
- Bladder is entirely filled with a large echogenic mass
(6.8x8.3x5.6). Arterial and venous bloodflow is identified
within the mass. Appearance consistent w/ urothelial carcinoma.
- No hydronephrosis. No cyst, stone or solid mass in either
kidney.
Brief Hospital Course:
ASSESSMENT & PLAN:
___ w/ recently diagnosed urothelial carcinoma, recurrent UTI,
h/o breast cancer, htn/hl, presented from her assisted living
facility w/ urosepsis. Found to have E. Coli. Treated for 10
days of Ceftriaxone IV. Pt had three stages of TURBT for removal
of bladder tumor (final biopsy pending). Had right nephrostomy
tube placed. Pt and family elected to pursue hospice rather than
raditation/chemotherapy. Patient will return to ___ and
be seen by Hospice team after leaving the hospital.
ACUTE PROBLEMS
# Urothelial Carcinoma - Recently diagnosed by urine cytology in
clinic on ___ by ___ urology. Bedside U/S showed full
bladder, mass and clot throughout, likely obstructed when she
was in the ED. A 3-way foley for CBI was placed in the ED.
Patient was transferred to the floor for management. The mass
likely is causing mild to moderate obstruction of the ureter
outlets into the bladder leading to mild obstruction. TURBT
performed ___ ___ however, unable to completely remove the
tumor. R perc nephrostomy placed on ___.
Stage 2 of the TURBT ___ (dual purpose: palliation of
obstructive symptoms as well as staging (i.e. muscular
invasion)) went well. Pt received two units of blood prior to
surgery. They were not able to remove the entire tumor during
stage 2 of the TURBT and had to have third stage to finish the
removal. Stage 3 of TURBT completed ___. The tumor invaded
into musculature, but full extent of invasion was not able to be
appreciated. The next stage would be be combined
chemo-radiation. The overall prognosis of the pt is poor even
with chemo-radiation. Given goals of care pt and family likely
to pursue hospice option.
Of note, Urology would possibly not offer curative surgery given
pt comorbitities and high risk of performing the case (chemo and
radiation would be a paliative option with a high morbidity).
Numerous goals of care discussions indicated pt and family would
rather pursue hospice vs chemotherapy/radiation given long term
outcomes and overall goals of care.
#Goals of Care- Pt, pt's sister, and pt's nephew along with Dr.
___ Dr. ___ goals of care discussion on
___. The conversation involved overall goals of care of the
pt and her wishes for continuing care. The patient needed
significant prompting in order to remember why she was still in
the hospital. She did indicate that she would rather not have to
go through chemotherapy and radiation again. She was told if she
received these treatments it would not be curative. The pt along
with the pt's sister (HCP) decided that the pt would not want to
go through chemo and would instead like to speak with hospice
nurses about pursuing hospice after leaving the hospital. Plan
is to discharge to ___ and pursue hospice as outpatient.
# Urosepsis- Pt presented with leukocytosis (WBC 14.3) and
slight confusion. She met ___ SIRS criteria (WBC, HR, RR). UA
was notable for many bac, large leuks and neg nitrite,
suggesting urinary source of infection on admission. Pt has
recently diagnosed urothelial carcinoma, in addition blood clots
in the bladder was noted in the ED. Obstruction thus likely made
the pt more susceptable to urinary source of infection. The neg
nitrite on UA suggest that it may not be a common gram negative
bacteria, such as e. coli. Avalaible past culture data showed
previous TETRACYCLINE-resistant enterococcus. pt has sulfa
allergy, she received zosyn x 1 in the ED and a dose of
ceftriaxone on the floor. On ___ UC grew E. Coli pan sensitive.
WBC of 21.1 on ___ likely secondary to stress reaction from
surgery. Pt completed her course of antibiotics and had no
recurrent infection. While in hospital. Patient had catheter for
urinary obstruction during her hospitalization. She had foley
D/C'd on day of discharge. She may have incontinence secondary
to surgery, and may require foley replaced.
# Delirium with chronic Dementia - AAO to person, hospital,
___ on arrival. slight confusion, but would catch
herself and correct her self. No fever, or neck stiffness, low
suspicion for encephlitis. The pt's delirium was likely mild
confusion in setting of infection. Delirium cleared on ___,
A+Ox3. Pt has underlying dementia which will likely result in
long term care. Pt is unable to make her own medical decision
and her sister (HCP) is needed to consent for any procedure.
Patient was at her baseline throughout hospitalization. Delirium
precautions were kept with good affect and should be continued
through her outpatient stay.
# ___ - Cr 2.1 on admission from recent level of 1.3. likely
multifactorial, including 1) pre-renal in the setting of poor PO
and sepsis and 2) post-renal in setting of blood clots in
bladder as well as urothelial carcinoma. CBI placed by urology
in the ED. CR 1.8 on ___. 2.2 on ___ with 300 UO over last
24hrs. Patient Cr 1.3 on ___ in AM with maintenance fluids
running at 250ml/hr since patient NPO. Cr 1.1 on ___.
Creatinine remained stable for the duration of her
hospitalization. She had R nephrostomy tube placed. After
conversations with Urology, ___ and Hospitalist team, pt and
family decided against bilateral nephrostomy tubes and will
discuss at later date if needed for hospice considerations.
CHRONIC ISSUES
# Anemia - hgb 7 on admission. recent baseline has been 7.3 to
8.1. MCV 94, normocytic. Blood clot noted from bladder
irrigation, but no gross hematuria. no additional source of
bleeding noted on initial exam. likely secondary to anemia of
chronic disease. Hgb on ___ was 6.9. patient received 1 unit of
PRBCs ___ in the ___ with follow up H/H showing appropriate
increase. Two units PRBCs ___ prior to surgery on ___.
HCT responded correctly to the units given prior to surgery. Pt
CBC stable on discharge. Maximize nutrition and supplements as
outpatient.
# HTN
We held lisinopril-hydrochlorothiazide ___ mg ORAL QD since
patient not hypertensive and in the setting of infection. We
will hold going forward and will be readdressed by hospice care.
TRANSITIONAL ISSUES
-pt may have incontinence secondary to recurrent TURBT and two
weeks of intermittent CBI; patient may need foley placement for
comfort for incontinence; foley was removed on ___
-pt has right nephrostomy tube in place and will f/u with
urology as outpatient
-pt will return to ___ and discuss hospice as outpatient
-pt was started on ___/opium suppositories 1 supp QHS for
bladder spasm; will need follow up with outpatient Urologist
-aspirin, HCTZ and lisinopril were discontinued as they were not
needed during hospital stay
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
3. lisinopril-hydrochlorothiazide ___ mg ORAL QD
4. Viactiv (calcium-vitamin D3-vitamin K) 0 mg ORAL QD
Discharge Medications:
1. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
2. Belladonna & Opium (16.2/30mg) 1 SUPP PR Q24 HRS Severe
bladder spasm
3. Viactiv (calcium-vitamin D3-vitamin K) 500-500-40 mg-unit-mcg
ORAL QD
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Sepsis, Urinary tract infection
Secondary Diagnosis: Bladder cancer
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear ___,
___ you for allowing us to take part in your care during your
stay in the hospital. You presented to the hospital after having
fever and difficulty urinating while at ___. You were
found to have an infection in your bladder. Prior to coming into
the hospital you were found to have a large tumor in your
bladder, concerning for an invasive cancer. You were seen by the
Urology team while in the hospital.
You were started on antibiotics for treatment of your UTI. You
remained without a fever after starting on antibiotics and did
not have any recurrent symptoms.
The urology team performed a TURBT (trans-urethral resection of
bladder tumor) to remove and stage the tumor. The procedure was
not curative but relieved the obstruction and your symptoms. The
procedure took place over three stages because the tumor was so
large. You also had a right sided nephrostomy tube placed since
there was concern of ureter obstruction or potential future
obstruction due to progression of the cancer.
After the final stage of the TURBT, we had a family meeting. You
and your family decided to not go through with chemotherapy and
radiation. You and your family will persue hospice care after
leaving the hospital and return to ___.
It has been a pleasure to care for you during your stay here at
___.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10141487-DS-9 | 10,141,487 | 24,889,188 | DS | 9 | 2119-08-11 00:00:00 | 2119-08-13 16:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Unresponsive
Major Surgical or Invasive Procedure:
Intubation ___
History of Present Illness:
=======================================
MICU RED RESIDENT ADMISSION NOTE
DATE OF ADMISSION:
=======================================
PCP: ___
CC: AMS
REASON FOR MICU: Intubated
HISTORY OF PRESENTING ILLNESS:
___ female with no known medical history presenting with
intoxication. Patient was found unconscious outside of her dorm
floor. Smells of alcohol with intial fingerstick of 176. She
vomited once during transport. On arrival to ED, patient with
GCS 6.
ED Course notable for:
Initial Vitals:
T 96.2; HR 76; BP 136/88; SpO2 96% on RA
Labs:
Utox negative
VBG: pH 7.49; pCO2 25; HCO3 20
CBC: WBC 7.6; Hgb 10.1
EtOH: 229
Imaging:
CT head: No acute process
CXR: No acute process. ET tube 3.6cm above carina.
Interventions:
Patient intubated
On arrival to the MICU, patient is intubated and sedated. She
opens her eyes to sternal rub.
Past Medical History:
Asthma
Iron deficiency anemia
Social History:
___
Family History:
non contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: HR 56; BP 109/69; SpO2 100%
GENERAL: Intubated and sedated
HEENT: Sclera anicteric, MMM. Pupils 2mm and minimally reactive.
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No rashes
NEURO: Intubated and sedated, opens eyes to sternal rub.
DISCHARGE:
VITALS: ___ 2351 Temp: 99.0 PO BP: 108/69 HR: 80 RR: 18 O2
sat: 99% O2 delivery: Ra
GENERAL: Alert and oriented, no acute distress
ENT: NT/AC, PERRLA, EOMI
CV: RRR, no murmurs, rubs, or gallops
RESP: CTAB, no wheezing
GI: NT/ND, BS+
Pertinent Results:
ADMISSION LABS:
___ 02:40AM BLOOD WBC-7.6 RBC-4.13 Hgb-10.1* Hct-33.4*
MCV-81* MCH-24.5* MCHC-30.2* RDW-14.3 RDWSD-41.8 Plt ___
___ 02:40AM BLOOD Neuts-56.6 ___ Monos-5.5 Eos-0.9*
Baso-0.4 Im ___ AbsNeut-4.30 AbsLymp-2.76 AbsMono-0.42
AbsEos-0.07 AbsBaso-0.03
___ 02:40AM BLOOD ___ PTT-27.1 ___
___ 02:40AM BLOOD Iron-24*
___ 02:40AM BLOOD calTIBC-354 Ferritn-11* TRF-272
___ 02:40AM BLOOD ASA-NEG ___ Acetmnp-NEG
Tricycl-NEG
___ 04:49AM BLOOD Type-ART pO2-185* pCO2-46* pH-7.31*
calTCO2-24 Base XS--3
___ 02:51AM BLOOD ___ pO2-106* pCO2-25* pH-7.49*
calTCO2-20* Base XS--1 Comment-GREEN TOP
___ 04:49AM BLOOD Lactate-1.4
___ 04:49AM BLOOD O2 Sat-99
IMAGING:
CT HEAD ___:
1. No acute intracranial abnormality on noncontrast head CT.
2. Dysconjugate gaze. Otherwise orbits are unremarkable.
CXR ___:
1. ETT terminates approximately 3.6 cm the carina.
2. Probable retrocardiac atelectasis with no definite focal
consolidations
identified.
MICRO:
None
Brief Hospital Course:
SUMMARY
=======
___ year old female w/ h/o asthma presented with alcohol
intoxication. She was admitted for intubation.
ACTIVE ISSUES
=============
# Acute alcohol intoxication
# Encephalopathy
Patient found unconscious outside of her dorm. GCS was 6 on
arrival to the ED. She was intubated for airway protection. EtOH
level found to be 229. Patient was afebrile without a white
count. No neck stiffness. Head CT was normal. She was on AC/VC
when she was in the ICU. Now she has been transitioned to
pressure support and weaned off sedation. She self-extubated the
afternoon of ___ and was transferred to the floor, where she
was breathing comfortably on room air. On the day of discharge
she was tolerating PO well, and denied any fevers, chills, chest
pain, nausea, vomiting, or diarrhea.
#Anemia
Patient has iron deficiency with ferritin 11. She states that
this is a chronic issue and that she has taken iron in the past
although she doesn't take it regularly. Plan to follow up with
local PCP for this.
# Asthma
Patient has PMH of asthma not on regular medication. States that
she does not use anything for this and has not had any recent
exacerbations. Plan to follow up with PCP.
TRANSITIONAL ISSUES
===================
[] Patient was told to take her ferrous sulfate regularly.
#CODE: FULL
#CONTACT: Patient lives in ___, does not want her parents to know
about this incident.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Alcohol Intoxication
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were intoxicated and there was concern for your breathing
so you were intubated.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- Were treated with intravenous fluids and were eventually able
to breath on your own again. You were transferred out of the ICU
and you felt well enough to be discharged home.
- While here you were found to have low iron levels.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- You should be very careful with alcohol intake in the future,
and should also avoid smoking or other drugs.
- You should take your iron pills regularly and call the number
listed below to get set up with a local PCP to follow up with
about your low iron levels.
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10141505-DS-18 | 10,141,505 | 24,681,640 | DS | 18 | 2204-06-04 00:00:00 | 2204-06-04 15:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Augmentin / Bactrim
Attending: ___
___ Complaint:
rectal pain, fever
Major Surgical or Invasive Procedure:
___ exam under anesthesia, incision and drainage of rectal
abscess
History of Present Illness:
___ man with history of diabetes, CAD, HTN, asthma, BPH and
recurrent UTIs, h/o DVT on warfarin with recent ED beside I&D of
rectal abscess by colorectal surgery on ___. Was doing well
at home until the night prior to admission when he started
having increasing rectal pain again worse with sitting or with
bowel movement, and shaking chills at home (did not take
temperature), so he presented to the ED. He denied cough, sore
throat, abdominal pain, N/V/D, dysuria, testicular pain or any
cuts or ulcers of his skin. No sick contacts or recent travel.
Does report occasional streaks of dark red blood on outside of
stools for the past week.
In the ED intial vitals were: 103.2 89 133/64 20 94% ra, 1
pressure of 97/51 was recorded, but improved back up to
systolics 130s-150s with 2L of NS, fever improved with 1g PO
acetaminophen. Labs showed normal chem 7, WBC 11.4 (88%pmn), INR
3.4, lactate 1.8, UA negative. CT abd/pelvis with contrast
showed interval decrease in perirectal abscess size without
other concerning findings on wet read. Patient was given 400mg
IV ciprofloxacin, 500mg IV metronidazole, and then another 500
mg PO acetaminophen later in the afternoon for recurrent fever.
He was evaluated by the colorectal surgery team who felt there
was not enough for I&D, but recommended admission to medicine
for work up of fever and leukocytosis. Vitals on transfer: ___
56 150/76 17 99% RA.
On the floor vitals were T 98.0, BP 130/74, HR 78, RR20, 94% RA.
He reports continued perirectal pain that is mild, sharp and
constant, worse with sitting up or with digital exam. He denies
shortness of breath but appears winded with mild exertion to
this MD to whom the patient is well known from outpatient
clinic.
Past Medical History:
- Lower extremity edema (DNK outpatient echo or cards appt in
___)
- Multiple E. Coli UTIs
- BPH (normal cystoscopy and CTU)
- CAD s/p Cypher DES to D1 in ___
- Asymptomatic bradycardia
- Asthma (though ___ spirometry more consistent with
restrictive defect)
- MI in ___ secondary to cocaine use
- Diabetes mellitus (on oral agents)
- Obstructive sleep apena, doesn't use CPAP
- Hypertension
- Hyperlipidemia
- Internal hemorrhoids, adenomatous polyps, diverticulosis
- Bilateral knee osteoarthritis s/p TKR ___ at ___
- Ineffective esophageal motility dx ___
- Hx of DVT's/PE's (last ___ on lifelong coumadin
- L TKR ___
Social History:
___
Family History:
One brother with asthma
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- T 98.0, BP 130/74, HR 78, RR20, 94% RA
General- Alert, oriented, pleasant and cooperative, speaking in
___ word sentences but appears winded with mild exertion
(repositioning)HEENT- Sclera anicteric, MMM, oropharynx clear,
EOMI, R pupil 3mm and reactive, L pupil 2mm and reactive (stable
from prior)
Neck- supple, JVP not elevated, no LAD
Lungs- Poor airmovement, rare crackles at bases, no rhonchi,
coarse breathsounds throughout
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops appreciated but heart sounds partially obscured by
coarse breath sounds
Abdomen- +BS, obese and distended but soft with reducible
umbilical hernia, non tender, no rebound or guarding
GU- no foley; penis normal without discharge or lesions,
testicles normal to palpation but patient reports mildly tender
to gentle palpation
Rectal: severe pain with finger insertion, no blood in vault,
unable to palpate lesion or mass
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, strength ___ in BUE and BLE, speaks with
a slight stutter (baseline)
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
ADMISSION LABS:
___ 09:10AM BLOOD WBC-11.4* RBC-4.48* Hgb-12.8* Hct-39.3*
MCV-88 MCH-28.7 MCHC-32.7 RDW-12.5 Plt ___
___ 09:10AM BLOOD Neuts-88.8* Lymphs-6.9* Monos-3.8 Eos-0.4
Baso-0.2
___ 09:10AM BLOOD ___ PTT-41.0* ___
___ 09:10AM BLOOD Glucose-189* UreaN-15 Creat-0.9 Na-137
K-3.9 Cl-100 HCO3-26 AnGap-15
___ 05:55AM BLOOD Calcium-8.3* Phos-3.9 Mg-1.6
___ 09:34AM BLOOD Lactate-1.8
CXR ___ - clear, no infiltrate, normal heart size, no
pleural effusion, prominent pulmonary vasculature
CT pelvis w contrast ___
Small perianal abscess, slightly smaller in size compared to the
recent prior study.
CT pelvis w contrast ___
Perianal abscess measures 2.3 x 2.2 x 2.6 cm.
Brief Hospital Course:
___ with CAD, HTN, DM2, asthma, BPH, recurrent UTIs, PE/DVT on
lifelong warfarin, with recent I&D of rectal abscess in ED
bedside by Colorectal Surgery on ___ who presented again
with Tm103.2 and rectal pain.
# Rectal abscess. Decreased size from prior. Febrile on
admission, now afebrile on antibiotics. Leukocytosis rising from
11.4 on admission to 16.7 on second day. Rigors at home raises
concern for bacteremia. Given rising leukocytosis and continued
intermittent rectal pain, will have I&D.
- Colorectal Surgery to take to OR today for exam under
anesthesia and I&D of abscess
- ciprofloxacin, metronidazole, ___
- follow up blood cultures
# Coronary artery disease.
- Continue aspirin, atorvastatin
- holding atenolol given SIRS
# Lower extremity edema. Patient has missed recent appointments
for echocardiogram and cardiology follow up, but edema has
resolved with initiation of low dose furosemide by PCP.
- holding furosemide given SIRS
# History of DVT on lifelong warfarin. INR supratherapeutic 3.4
on admission.
- cont warfarin at reduced dose to 1.5mg given
cipro/metronidazole interactions
# Asthma:
- continue albuterol, flovent
# Diabetes:
- Hold glyburide and metformin while inpatient
- Insulin sliding scale, QID finger sticks and diabetic diet
# Hypertension: Currently normotensive.
- hold atenolol, valsartan until concern for SIRS resolves
# Impaired esophageal motility:
- Continue omeprazole
# BPH:
- Hold doxazosin until concern for active sepsis resolves
# FEN: IVF as needed, replete electrolytes, regular diet
# Prophylaxis: systemic anticoagulation on warfarin, bowel
regimen, pain control with APAP, tramadol
# Access: peripherals
# Code: Full, confirmed with patient ___
# Communication: Patient
# Emergency Contact: Girlfriend/HCP ___
___
# Disposition: likely to Colorectal Surgery service after OR
Postoperatively the patient was admitted to the Colorectal
Inpatient Service. He was monitored closely overnight. 1.5mg of
Coumadin was given which is a smaller dose of the patient's home
dose as he was given antibiotoic and his INR was 2.9. On
post-operative da one the packing from the patients perineal
wound was removed. It no longer required packing. The patient's
pain was controlled with medications by mouth. He tolerated a
regular diet. He was to restart his normal doses of coumadin at
home as he would no longer be taking antibiotic therapy. His
PCP's office was notified of his discharge. The patient was
asked to have his INR checked on ___. He can walk into his
PCP's office for a check. He was seen by the surgical attending
and cleared for discharge. The patient was provided with
appropriate discharge instructions. He was also educated on the
importance of blood glucose managment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nitroglycerin SL 0.3 mg SL PRN chest pain
2. Warfarin 3 mg PO 2X/WEEK (MO,TH)
3. Warfarin 2 mg PO 5X/WEEK (___)
4. Flovent HFA (fluticasone) 220 mcg/actuation inhalation BID
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB or wheeze
6. Docusate Sodium 100 mg PO BID
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Doxazosin 8 mg PO HS
10. Valsartan 40 mg PO DAILY
11. Atenolol 25 mg PO DAILY
12. Aspirin 81 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. GlyBURIDE 10 mg PO BID
15. Atorvastatin 80 mg PO DAILY
16. Furosemide 20 mg PO DAILY
17. Hydrocortisone (Rectal) 2.5% Cream ___AILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Omeprazole 20 mg PO DAILY
5. Polyethylene Glycol 17 g PO DAILY constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram 17 gm by mouth
once a day Disp #*30 Each Refills:*0
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB or wheeze
7. Atenolol 25 mg PO DAILY
8. Doxazosin 8 mg PO HS
9. Flovent HFA (fluticasone) 220 mcg/actuation inhalation BID
10. Furosemide 20 mg PO DAILY
11. GlyBURIDE 10 mg PO BID
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. Valsartan 40 mg PO DAILY
14. Warfarin 3 mg PO 2X/WEEK (MO,TH)
15. Warfarin 2 mg PO 5X/WEEK (___)
16. Acetaminophen 650 mg PO Q6H:PRN pain or fever
do not give more than 3000mg in 24 hours or drink alcohol
RX *acetaminophen 325 mg ___ tablet(s) by mouth every six (6)
hours Disp #*45 Tablet Refills:*0
17. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
do not drink alcohol or drive a car while taking this medication
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*35 Tablet Refills:*0
18. Nitroglycerin SL 0.3 mg SL PRN chest pain
Discharge Disposition:
Home
Discharge Diagnosis:
Perirectal Abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the inpatient Colorectal Surgery Service
after surgery for managment of your perirectal abscess. This was
done in the operating room. You have a large open wound in the
area of the abcess. This no longer needs to be packed however,
you may apply a sterile dressing to your underwear to catch the
drainage. Please inspect the site daily with a mirror, if you
notice that you are having increased pain or increased
grey/green/white drainage, or swelling around the wound please
call the office. you should shower daily and let the warm soapy
water run over the area. You should take a tube bath after bowel
movements. It is important to keep the area as clean as
possible. Please call us if you develop a fever greater than
100.0. The treatment for this condition is drainage which you
have had. Antibiotics are not needed at this time. It will be
important that you keep your blood sugar under control to
decrease your risk for infection even more. Please call the
office with any concerns or symptoms.
Please monitor your bowel function closely. You may or may not
have had a bowel movement prior to your discharge which is
acceptable, however it is important that you have a bowel
movement in the next ___ days. After anesthesia it is not
uncommon for patients to have some decrease in bowel function
but you should not have prolonged constipation. Some loose stool
and passing of small amounts of dark, old appearing blood are
expected. However, if you notice that you are passing bright red
blood with bowel movements or having loose stool without
improvement please call the office or go to the emergency room
if the symptoms are severe. If you are taking narcotic pain
medications there is a risk that you will have some
constipation. Please take an over the counter stool softener
such as Colace, and if the symptoms do not improve call the
office. If you have any of the following symptoms please call
the office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or extended constipation.
You will be prescribed a small amount of the pain medication
Oxycodone. Please take this medication exactly as prescribed.
You may take Tylenol as recommended for pain. Please do not take
more than 3000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
No heavy lifting greater than 6 lbs for until your first
post-operative visit after surgery. Please no strenuous activity
until this time unless instructed otherwise by Dr. ___ Dr.
___.
You my go back to taking your home dose of Coumadin. Please have
your INR checked ___. Your INR has been therapeutic, on
last check ___ it was 2.9. Please have this checked at your
regular ___.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
___
|
10141577-DS-4 | 10,141,577 | 28,822,575 | DS | 4 | 2169-08-10 00:00:00 | 2169-08-10 14:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L sided chest pain x 2 days
Major Surgical or Invasive Procedure:
none this admission
Mitral Valve Replacement (31mm ___ mechanical valve) ___
History of Present Illness:
Mrs. ___ is a ___ yo woman who
underwent a mechanical MVR on ___. She spent a few days in the
ICU post operatively weaning from pressors and inotropes and was
discharged home on POD10. She has been doing well at home until
a couple of days ago when she developed L sided chest pain
described as inside her breast, worse with breathing and
position
change and better with rest. She reports a non-productive cough
which has increased recently. She has had intermittent chills
and
fevers and her temp was 100.6 at the outside hospital tonight.
Her CXR was suggestive of a L sided infiltrate and she was
transfered for further evaluation
Past Medical History:
supratherapeutic INR
PMH:
mitral valve regurgitation s/p MVR
mitral valve prolapse
Social History:
___
Family History:
Non-contributory
Physical Exam:
Pulse:87 SR Resp:18 O2 sat:100% on RA
B/P Right:117/77 Left:
Height: Weight:
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Sharp valve click
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x] No Edema [x] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
DP Right:2+ Left:2+
___ Right:2+ Left:2+
Radial Right:2+ Left:2+
sternal incision well healed, no erythema or drainage sternum
stable
Pertinent Results:
___ Echo
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are ___ with moderate global
hypokinesis (LVEF= 35 %). The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis. No aortic
regurgitation is seen. A mechanical mitral valve prosthesis is
present. The mitral prosthesis appears well seated, with normal
disc motion and transvalvular gradients. Trivial mitral
regurgitation is seen. [The severity of mitral regurgitation may
be UNDERestimated due to acoustic shadowing.] There is mild
pulmonary artery systolic hypertension. There is a very small
pericardial effusion around the distal right ventricle and apex
without echocardiographic signs of tamponade.
IMPRESSION: Well seated, normal functioning bileaflet mitral
valve prosthesis. Moderate global biventricular hypokineiss.
Very small pericardial effusion without echocardiographic
evidence of tamponade. Pulmonary hypertension.
Compared with the prior study (images reviewed) of ___, the
mitral valve has been replaced with a normal functioning
bileaflet prosthesis, left ventricular systolic function is more
depressed, and the estimated PA systolic pressure is now lower.
___ 08:25AM BLOOD WBC-7.1 RBC-3.46* Hgb-10.2* Hct-33.3*
MCV-96 MCH-29.6 MCHC-30.7* RDW-14.2 Plt ___
___ 04:35PM BLOOD WBC-10.3 Hct-31.1*
___ 05:20AM BLOOD WBC-10.1 RBC-3.39* Hgb-10.1* Hct-32.9*
MCV-97 MCH-29.8 MCHC-30.6* RDW-14.2 Plt ___
___ 08:05AM BLOOD ___
___ 08:25AM BLOOD ___ PTT-50.9* ___
___ 04:35PM BLOOD ___ PTT-55.2* ___
___ 05:20AM BLOOD ___ PTT-52.0* ___
___ 01:45PM BLOOD ___ PTT-48.1* ___
___ 01:35AM BLOOD ___ PTT-67.5* ___
___ 08:25AM BLOOD Glucose-85 UreaN-9 Creat-0.6 Na-140 K-3.9
Cl-100 HCO3-32 AnGap-12
___ 05:20AM BLOOD Glucose-173* UreaN-10 Creat-0.6 Na-136
K-4.0 Cl-103 HCO3-25 AnGap-12
___ 01:35AM BLOOD Glucose-109* UreaN-12 Creat-0.6 Na-136
K-3.6 Cl-99 HCO3-24 AnGap-17
Brief Hospital Course:
Mrs. ___ was admitted for further work-up and found to
have an INR of 8.5. She received 2 units of FFP and INR trended
down to 3.4. Additionally, echo revealed small pericardial
effusion without signs of tamponade. EP was consulted for her
history of Wenckebach. She was monitored with ___ of Hearts.
This showed no evidence of atrial fibrillation and EP
recommended stopping Amiodarone and avoiding any beta blockers.
Coumadin 2 mg was given on ___ for INR 3.4 and INR was to be
drawn on ___ and ___ at the ___. Couamdin
dosing to be managed by Dr. ___ INR goal 2.5-3.5. CXR
showed small-moderate pleural effusion at the time of discharge
and she was diuresed with Lasix - saturation was 93% on room
air. On hospital day 4, she was tolerating a full oral diet, INR
was therapuetic at 3.4 and she was ambulating without
difficulty. It was felt that she was safe for discharge home at
this time. All coumadin dosing and INR levels faxed to ___
___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin EC 81 mg PO DAILY
2. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
3. Furosemide 20 mg PO DAILY
4. Potassium Chloride 20 mEq PO DAILY
5. Warfarin 5 mg PO DAILY16
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Furosemide 20 mg PO DAILY Duration: 7 Days
RX *furosemide [Lasix] 20 mg 1 tablet(s) by mouth daily Disp #*7
Tablet Refills:*0
3. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
4. Warfarin 2 mg PO DAILY16
RX *warfarin [Coumadin] 2 mg 1 tablet(s) by mouth daily or as
instructed Disp #*60 Tablet Refills:*0
5. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days
RX *potassium chloride [Klor-Con M20] 20 mEq 1 tab by mouth
daily Disp #*7 Tablet Refills:*0
Discharge Disposition:
Home with Service
Discharge Diagnosis:
supratherapeutic INR
PMH:
mitral valve regurgitation s/p MVR
mitral valve prolapse
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tramadol
Incisions:
Sternal - healing well, no erythema or drainage
Edema none
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns ___
*Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10141695-DS-11 | 10,141,695 | 29,073,061 | DS | 11 | 2131-03-24 00:00:00 | 2131-03-27 17:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: ___ drain placement
History of Present Illness:
___ with PMHx of ___ transferred from ___ with
diagnosis of perforated acute appendicitis and now seen in
consultation by ACS for further evaluation. Patient presented to
___ after 1 day of RLQ sharp abdominal pain that limited
her ambulation. Over the past day, the pain became progressively
worse prompting her a visit to the ___. At ___ patient was
found febrile to 102, tachycardic to 117 and with laboratory
data
revealing a leukocytosis to 17.6. CT abdomen demonstrated a
markedly inflamed appendix measuring 13mm surrounding by fat
stranding and associated with a 3 cm periappendiceal abscess.
Patient received a dose of Zosyn an transferred to ___
for further management.
Upon arrival to the ___, 101.9, 135, 120/73, 18, 97% RA. Repeat
laboratory work up demonstrated decrease leukocytosis to . Upon
examination, abdomen was tender to palpation and rebound to RLQ.
Past Medical History:
HTN
Family History:
noncontributory
Physical Exam:
Physical Exam:
Vitals:101.9, 135, 120/73, 18, 97% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Tender to palpation to RLQ with rebound.
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 05:20AM BLOOD WBC-17.6* RBC-3.47* Hgb-10.6* Hct-32.5*
MCV-94 MCH-30.5 MCHC-32.6 RDW-12.7 RDWSD-42.7 Plt ___
___ 06:15AM BLOOD WBC-19.7* RBC-3.49* Hgb-10.8* Hct-32.8*
MCV-94 MCH-30.9 MCHC-32.9 RDW-12.7 RDWSD-42.8 Plt ___
___ 06:00AM BLOOD WBC-18.3* RBC-3.35* Hgb-10.4* Hct-31.8*
MCV-95 MCH-31.0 MCHC-32.7 RDW-12.5 RDWSD-42.7 Plt ___
___ 06:02AM BLOOD WBC-16.8* RBC-3.34* Hgb-10.2* Hct-31.7*
MCV-95 MCH-30.5 MCHC-32.2 RDW-12.3 RDWSD-42.4 Plt ___
___ 06:01AM BLOOD WBC-14.8* RBC-3.30* Hgb-10.1* Hct-30.6*
MCV-93 MCH-30.6 MCHC-33.0 RDW-11.9 RDWSD-40.6 Plt ___
___ 04:40AM BLOOD WBC-11.2* RBC-3.31* Hgb-10.4* Hct-30.5*
MCV-92 MCH-31.4 MCHC-34.1 RDW-11.8 RDWSD-39.9 Plt ___
___ 01:09AM BLOOD WBC-12.8*# RBC-3.73* Hgb-11.7 Hct-33.9*
MCV-91 MCH-31.4 MCHC-34.5 RDW-11.7 RDWSD-38.9 Plt ___
Imaging:
___ CT abdomen & pelvis: appreciate inflammed appendix
dilated to
13mmm surrounded by fat stranding. Multiple bowel loops with
local edema, mostly at RUQ. There is a 3x1.1 cm periappendiceal
abscess.
___ CTAP: 1. Interval increase in fluid collection
containing air in the right lower quadrant at site of prior
perforated appendix, which extends along the cul-de-sac and
anterior to the uterus, with adjacent bowel inflammation causing
small bowel obstruction.
2. Small Bilateral pleural effusions and atelectasis.
___: CT-guided placement of an ___ pigtail catheter
into the collection with aspiration of 10 cc serosanguineous
fluid. Samples was sent for microbiology evaluation.
___ CTAP:
1. Interval placement of pigtail catheter within a previously
described right lower quadrant multiloculated fluid collection
with no significant change in size and persistent locules of
air. A fluid collection within the cul-de-sac as well as
anterior to the uterus persist, the former which demonstrates
new rim enhancement. Edematous adjacent bowel results in
statis/early small bowel obstruction which is unchanged in
appearance.
2. Interval decrease in size of small bilateral pleural
effusions. A
pericardial effusion is small.
___: Successful CT-guided up-sizing of a pigtail catheter
into the RLQ collection, now with a ___ catheter.
Brief Hospital Course:
The patient was transferred to ___ from an outside hospital on
___ for evaluation and treatment of abdominal pain. OSH
abdominal/pelvic CT revealed perforated acute appendicitis and a
3cm periappendiceal abscess. WBC was elevated at 12.8. The
patient was admitted to the General Surgical Service for bowel
rest, IV antibiotics, IV fluids, and serial exams. On HD3, WBC
had risen to 14.8 and patient was still very tender on exam.
Repeat CT showed interval increase in abscess. Interventional
Radiology was consulted, and the patient underwent ___ drainage
and drain placement, which went well without complication. The
drain was upsized on the following day, due to scant output. The
patient's abdominal exam was improving and she was started on a
diet.
.
When tolerating a diet, the patient was converted to oral pain
medication and oral antibiotics 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. She was given drain teaching and was able to
demonstrate drain emptying and flushing. The patient was
discharged home with ___ services for drain care. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
She was to complete a 2-week course of cipro/flagyl and follow
up in ___ clinic.
Medications on Admission:
Medications: HCTZ 25'
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain/headache
RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*17 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
4. Hydrochlorothiazide 25 mg PO DAILY
5. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
four (4) hours Disp #*25 Tablet Refills:*0
6. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*25 Tablet Refills:*0
7. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Ruptured appendicitis with periappendical abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented to ___ with abdominal pain and were found to
have ruptured appendicitis with periappendical abscess. You were
admitted for bowel rest and IV antibiotics. A repeat CT scan
showed the abscess was getting larger, so you were taken to
Interventional Radiology and underwent drainage of the abscess.
A drain was left in place. You are now tolerating a regular diet
and your pain is well controlled. You are ready to be discharged
home to continue your recovery. You will have a prescription to
complete a course of antibiotics and will have a visiting nurse
to help you with drain care. Please note the following discharge
instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash drain site with a mild soap and warm
water. Gently pat the area dry.
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.
*Flush drain three times a day
Followup Instructions:
___
|
10141911-DS-16 | 10,141,911 | 23,690,373 | DS | 16 | 2169-12-20 00:00:00 | 2169-12-20 09:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain nausea and emesis in the setting of AAA
Major Surgical or Invasive Procedure:
Endovascular Aneurysm Repair of Abdominal Aorta
History of Present Illness:
Mr. ___ is a ___ male patient with a history of
hypothyroidism, heart conduction disease who presents to the ED
with a 7.9 AAA. He reports that he has been having mild
abdominal pain nausea and emesis for the past 2 weeks. Given
that his abdominal pain and nausea did not resolve he decided to
come to the emergency department at an outside hospital. At the
outside hospital he underwent an abdominal ultrasound which
showed abdominal aortic aneurysm for which she underwent CT scan
of the abdomen and pelvis. The CT scan showed again an
infrarenal abdominal aortic aneurysm measuring 7.9 cm but
without
signs of rupture or dissection. Given that this was a new
finding, he was we are consulted for possible surgical
management. Transferred to ___ for management.
The patient reports mild abdominal discomfort. He denies
chills,
fevers, chest pain, palpitations, and shortness of breath. He
reports that he is independent at home and he is able to walk
using a walker that he walks short distances. He denies any
chest pain or shortness of breath while walking but does get
tired.
Past Medical History:
PMH:
Hypothyroidism
conductive system disease
syncope
RBBB
Orthostatic hypotension
PSH:
Varicose vein treatment
Thyroid lobectomy
Social History:
___
Family History:
Noncontributory
Physical Exam:
At discharge
Temp: 97.7 (Tm 99.5), BP: 124/63 (124-171/48-78), HR: 70
(68-78), RR: 17 (___), O2 sat: 95% (94-97), O2 delivery: Ra,
Wt: 183.64 lb/83.3 kg
GENERAL: NAD; A/O x 3
CV: RRR
PULM: no respiratory distress
ABD: soft Nontender nondistended
WOUND: bilateral groins soft, no bleeding or evidence of
hematoma
EXTREMITIES:no CCE
PULSES: palpable pedal pulses bilaterally
Brief Hospital Course:
Patient was admitted on ___ after presenting to an OSH with
complaints of nausea and vomiting, and CT scan showing
infrarenal abdominal aortic aneurysm measuring 7.9 cm but
without signs of rupture or dissection. He was admitted to the
ICU for BP control with goal of SBP less than 120. A CTA was
ordered for further characterization and for preoperative
planning, and a vascular medicine consult was placed for medical
optimization. He was started on a nicardipine drip and labetalol
for pressure control. His pressures continued to be controlled
in the ICU and the abdominal pain resolved on HOD 1. On HOD 2
nicardipine drip started to be weaned and BP continued to be
under control, and he remained asymptomatic. On ___ he
underwent an EVAR with aptus screws. The procedure was
successful with no evidence of endoleak. Following the procedure
he continued to do well, with BP well controlled, and the
nicardipine was completely weaned off. He was started on a
statin, and ASA was continued. He had no abdominal pain, no back
pain, or any motor or sensory deficits. He was medically cleared
for discharge on POD 1, but had difficulties moving out of bed.
___ was consulted and recommended acute rehab. He was discharge
on ___ for rehab for physical therapy.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, moving out of bed with assistance, voiding without
assistance, and pain was well controlled. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Midodrine 2.5 mg PO TID
3. Aspirin 81 mg PO DAILY
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
7. Ferrous Sulfate 325 mg PO DAILY
8. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever
9. Cyanocobalamin 1000 mcg PO DAILY
10. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
2. Heparin 5000 UNIT SC TID
3. Labetalol 50 mg PO TID
RX *labetalol 100 mg 0.5 (One half) tablet(s) by mouth three
times a day Disp #*30 Tablet Refills:*1
4. Polyethylene Glycol 17 g PO DAILY
5. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever
6. Aspirin 81 mg PO DAILY
7. Cyanocobalamin 1000 mcg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Ferrous Sulfate 325 mg PO DAILY
10. Levothyroxine Sodium 100 mcg PO DAILY
11. Midodrine 2.5 mg PO TID
12. Omeprazole 20 mg PO DAILY
13. Senna 8.6 mg PO BID:PRN Constipation - First Line
14. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Symptomatic infrarenal abdominal aortic aneurysm.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure taking care of you at ___
___. You were admitted to the hospital after
placement of a stent graft in your aorta to strengthen the part
of the artery that was weakened by an aneurysm. To perform this
procedure, small punctures were made in the arteries on both
sides of your groin. You tolerated the procedure well and are
now ready to be discharged from the hospital. Please follow
the recommendations below to ensure a speedy and uneventful
recovery.
Division of Vascular and Endovascular Surgery
Endovascular Abdominal Aortic Aneurysm Repair Discharge
Instructions
PLEASE NOTE: After endovascular aortic repair (EVAR), it is very
important to have regular appointments (every ___ months) for
the rest of your life. These appointments will include a CT
(CAT) scan and/or ultrasound of your graft. If you miss an
appointment, please call to reschedule.
WHAT TO EXPECT:
Bruising, tenderness, and a sensation of fullness at the groin
puncture sites (or incisions) is normal and will go away in
one-two weeks
CARE OF THE GROIN PUNCTURE SITES:
It is normal to have mild swelling, a small bruise, or small
amounts of drainage at the groin puncture sites. In two weeks,
you may feel a small, painless, pea sized knot at the puncture
sites. This too is normal. Male patients may notice swelling
in the scrotum. The swelling will get better over one-two
weeks.
Look at the area daily to see if there are any changes. Be
sure to report signs of infection. These include: increasing
redness; worsening pain; new or increasing drainage, or drainage
that is white, yellow, or green; or fever of 101.5 or more. (If
you have taken aspirin, Tylenol, or other fever reducing
medicine, wait at least ___ hours after taking it before you
check your temperature in order to get an accurate reading.)
FOR SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
If you have sudden, severe bleeding or swelling at either of
the groin puncture sites:
-Lie down, keep leg straight and apply (or have someone apply)
firm pressure to area for ___ minutes with a gauze pad or
clean cloth.
-Once bleeding has stopped, call your surgeon to report what
happened.
-If bleeding does not stop, call ___ for transfer to closest
Emergency Room.
You may shower 48 hours after surgery. Let the soapy water
run over the puncture sites, then rinse and pat dry. Do not rub
these sites and do not apply cream, lotion, ointment or powder.
Wear loose-fitting pants and clothing as this will be less
irritating to the groin puncture sites.
MEDICATIONS
Take aspirin daily. Aspirin helps prevent blood clots that
could form in your repaired artery.
It is very important that you never stop taking aspirin or
other blood thinning medicines-even for a short while- unless
the surgeon who repaired your aneurysm tells you it is okay to
stop. Do not stop taking them, even if another doctor or nurse
tells you to, without getting an okay from the surgeon who first
prescribed them.
You will be given prescriptions for any new medication started
during your hospital stay.
Before you go home, your nurse ___ give you information about
new medication and will review all the medications you should
take at home. Be sure to ask any questions you may have. If
something you normally take or may take is not on the list you
receive from the nurse, please ask if it is okay to take it.
PAIN MANAGEMENT
Most patients do not have much pain following this procedure.
Your puncture sites may be a little sore. This will improve
daily. If it is getting worse, please let us know.
You will be given instructions about taking pain medicine if
you need it.
ACTIVITY
You must limit activity to protect the puncture sites in your
groin. For ONE WEEK:
-Do not drive
-Do not swim, take a tub bath or go in a Jacuzzi or hot tub
-Do not lift, push, pull or carry anything heavier than five
pounds
-Do not do any exercise or activity that causes you to hold your
breath or bear down with your abdominal muscles.
-Do not resume sexual activity
Discuss with your surgeon when you may return to other regular
activities, including work. If needed, we will give you a
letter for your workplace.
It is normal to feel weak and tired. This can last six-eight
weeks, but should get better day by day. You may want to have
help around the house during this time.
___ push yourself too hard during your recovery. Rest when
you feel tired. Gradually return to normal activities over the
next month.
We encourage you to walk regularly. Walking, especially
outdoors in good weather is the best exercise for circulation.
Walk short distances at first, even in the house, then do a
little more each day.
It is okay to climb stairs. You may need to climb them slowly
and pause after every few steps.
DIET
It is normal to have a decreased appetite. Your appetite will
return over time.
Follow a well balance, heart-healthy diet, with moderate
restriction of salt and fat.
Eat small, frequent meals with nutritious food options (high
fiber, lean meats, fruits, and vegetables) to maintain your
strength and to help with wound healing.
BOWEL AND BLADDER FUNCTION
You should be able to pass urine without difficulty. Call you
doctor if you have any problems urinating, such as burning,
pain, bleeding, going too often, or having trouble urinating or
starting the flow of urine. Call if you have a decrease in the
amount of urine.
You may experience some constipation after surgery because of
pain medicine and changes in activity. Increasing fluids and
fiber in your diet and staying active can help. To relief
constipation, you may talk a mild laxative. Please take to
your pharmacist for advice about what to take.
SMOKING
If you smoke, it is very important that you STOP. Research
shows smoking makes vascular disease worse. This could increase
the chance of a blockage in your new graft. Talk to your
primary care physician about ways to quit smoking.
CALLING FOR HELP/DANGER SIGNS
If you need help, please call us at ___. Remember,
your doctor, or someone covering for your doctor, is available
24 hours a day, seven days a week. If you call during
nonbusiness hours, you will reach someone who can help you reach
the vascular surgeon on call.
Call your surgeon right away for:
Pain in the groin area that is not relieved with medication,
or pain that is getting worse instead of better
Increased redness at the groin puncture sites
New or increased drainage from the groin puncture sites, or
white yellow, or green drainage
Any new bleeding from the groin puncture sites. For sudden,
severe bleeding, apply pressure for ___ minutes. If the
bleeding stops, call your doctor right away to report what
happened. If it does not stop, call ___
Fever greater than 101.5 degrees
Nausea, vomiting, abdominal cramps, diarrhea or constipation
Any worsening pain in your abdomen
Problems with urination
Changes in color or sensation in your feet or legs
CALL ___ in an EMERGENCY, such as
Any sudden, severe pain in the back, abdomen, or chest
A sudden change in ability to move or use your legs
Sudden, severe bleeding or swelling at either groin site that
does not stop after applying pressure for ___ minutes
Please make an appointment with your PCP ideally one week after
leaving the hospital
Followup Instructions:
___
|
10141955-DS-12 | 10,141,955 | 24,201,243 | DS | 12 | 2148-03-11 00:00:00 | 2148-03-13 14:38:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Percocet / Vicodin
Attending: ___.
Chief Complaint:
Back pain, Abdominal pain, Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ F w/ IBS recently discharged from ___ on
___ following discectomy and laminectomy presenting from her
rehab with fever, N/V, and abdominal pain. Patient brought back
to ED from ___ for fever to 101.9, abd pain, and constipation.
Has associated chills, anorexia, night sweats, and chronic cough
that she relates to asthma. She reports single episode of
"black" post-tussive emesis. No BM in at least 4 days prior to
presenation. Also c/o urinary retention since surgery. Denies
chest pain, palpitations, HA, dizziness, lightheadedness,
weakness, or numbness.
ED course;
- VS: 100.2 96 134/70 18 97%RA
- Diffuse abdominal TTP with voluntary guarding. No rebound
- DRE: no fecolith or stool impaction
- UA 47 WBC, no bacteria
- CT Abd/Pelv: no acute processes
- KUB: distended large bowel with air in the rectum.
- Neurosurgery c/s: low-grade temps likely due to atelectasis
without concern for issues related to surgical site
- Foley placed; drained 1,000+ cc urine
- admit to medicine for further monitoring/work-up of fever
Patient reports abdominal discomfort is much improved after
placement of Foley. Still has some LLQ pain, but improved by
pain medication. She believes pain is mostly due to
constipation.
ROS: Full 10 pt review of systems negative except for above.
Denies chest pain or dyspnea.
Past Medical History:
- DM2 (diet controlled)
- HTN
- Dyslipidemia
- Anxiety
- GERD
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION:
VS: 99.3 125/83 HR 92 sat 98% on RA
Gen: NAD
HEENT: clear OP
CV: NR, RR, no murmur
Pulm: CTAB, nonlabored
Abd: soft, mild LLQ tenderness, no guarding or rebound
Back: Staples over lower midline L-spine intact with mild
surrounding erythema, but no TTP; serosanguinous fluid but no
palpable fluid collections
GU: Foley in place
Ext: no edema
Skin: no lesions noted
Neuro: A&O, moving all ext, ___ strength
Psych: appropriate affect
DISCHARGE:
VS: 98.6, 98.1, 57-102, 98-128/61-88, ___, 96%RA
Gen: NAD
HEENT: clear OP
CV: NR, RR, no murmur
Pulm: CTAB, nonlabored
Abd: BS+, softly distended, no rebound or guarding
Back: Staples over lower midline L-spine intact with mild
surrounding erythema, but no TTP; serosanguinous fluid but no
palpable fluid collections
GU: Foley in place
Ext: no edema
Skin: no lesions noted
Neuro: A&O, moving all ext, ___ strength
Psych: appropriate affect
Pertinent Results:
ADMISSION LABS:
___ 04:40AM BLOOD WBC-10.5 RBC-3.93* Hgb-9.7* Hct-32.0*
MCV-81* MCH-24.7* MCHC-30.4* RDW-16.8* Plt ___
___ 06:50AM BLOOD WBC-6.5 RBC-4.04* Hgb-10.2* Hct-32.7*
MCV-81* MCH-25.3* MCHC-31.3 RDW-16.6* Plt ___
___ 04:40AM BLOOD Neuts-82.3* Lymphs-11.7* Monos-4.2
Eos-1.6 Baso-0.2
___ 04:40AM BLOOD ___ PTT-26.7 ___
___ 04:40AM BLOOD Glucose-102* UreaN-13 Creat-1.0 Na-140
K-3.8 Cl-105 HCO3-22 AnGap-17
___ 06:50AM BLOOD Glucose-90 UreaN-9 Creat-0.8 Na-141 K-3.7
Cl-104 HCO3-31 AnGap-10
___ 04:40AM BLOOD ALT-23 AST-67* TotBili-0.5
___ 04:40AM BLOOD Albumin-3.5 Calcium-9.2 Phos-2.0*# Mg-2.1
___ 04:41AM BLOOD Lactate-1.7
DISCHARGE:
___ 07:45AM BLOOD WBC-8.2 RBC-4.26 Hgb-10.7* Hct-34.6*
MCV-81* MCH-25.2* MCHC-31.0 RDW-16.4* Plt ___
___ 07:45AM BLOOD Glucose-87 UreaN-16 Creat-1.1 Na-138
K-3.9 Cl-100 HCO3-25 AnGap-17
___ 07:45AM BLOOD Calcium-9.3 Phos-4.4 Mg-1.7
IMAGING:
- CT abd/pelv w/ contrast ___ IMPRESSION:
1. No acute intra-abdominal process. Gaseous distention of large
bowel without
obstruction.
2. Small ascites is nonspecific and of unknown significance.
3. Small-moderate hiatal hernia.
.
- CXR ___ IMPRESSION: No pneumonia, edema or pleural
effusion
Brief Hospital Course:
Ms. ___ is a ___ F w/ IBS recently discharged from ___ on
___ following discectomy and laminectomy presenting from her
rehab with fever, N/V, and abdominal pain. Patient found to have
urinary retention and constipation.
# Fever: Unclear etiology. Temp to 101.9 at ___ prior to
admission. No fevers once on medicine floor. Urinalysis 47 WBC,
neg nitrite, no bacteria in ED. CXR in ED unremarkable. She
remained afebrile for the duration of hospitalization off of
antibiotics and there was no concern for infection of the
surgical site.
# Urinary retention: Failed voiding trial on ___. Foley was
replaced. She will be discharged with the catheter for voiding
trial at rehab. Also has urology appointment in the event that
she continues to retain at rehab. She has had this issue with
prior surgeries and this is likely due to narcotics.
# Vomiting: Possibly had hematemesis per patient's report of
black color. Possibly due to gastritis. Could also be related to
recent constipation or opiates. She was continued on her home
PPI and had one episode of emesis.
# Constipation: Several BMs ___ ___ and ___ ___. After
aggressive bowel regimen she developed loose stools so
medication frequency was reduced.
# s/p Laminectomy/Discectomy: Evaluated by Neurosurgery in ED,
and no concerns w/ surgical site or for infectious source in
back. The wound had serosanguinous drainage and staples should
remain in until ___.
# DM Type II: diet controlled. No known complications. She was
placed on an insulin sliding scale while in the hospital.
# Hypertension: Continue Amlodipine
# Dyslipidemia: Continued on home statin.
# Anxiety: stable
# GERD: PPI as above
#CONTACT: ___ (daughter) ___ ___
___ (son) ___
# CODE: Full- confirmed
TRANSITIONAL ISSUES:
-voiding trial at rehab, may require straight cath vs.
replacement of ___ as she failed first trial. Has urology
appointment that can be cancelled if she is able to void.
-narcotics should be tapered as tolerated given the high doses
-staples need to be removed on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Bisacodyl 10 mg PO/PR BID:PRN constipation
3. Diazepam 5 mg PO Q6H:PRN spasm/anxiety
4. Famotidine 20 mg PO BID
5. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
6. Paroxetine 10 mg PO DAILY
7. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Bisacodyl 10 mg PO/PR BID:PRN constipation
3. Diazepam 5 mg PO Q6H:PRN spasm/anxiety
RX *diazepam 5 mg 1 tab by mouth every six (6) hours Disp #*28
Tablet Refills:*0
4. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN pain
RX *hydromorphone 4 mg 1 tablet(s) by mouth every four (4) hours
Disp #*42 Tablet Refills:*0
5. Paroxetine 10 mg PO DAILY
6. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
7. Acetaminophen 1000 mg PO Q8H
8. Docusate Sodium 100 mg PO BID
9. Morphine SR (MS ___ 45 mg PO Q12H
RX *morphine 30 mg 1 tablet extended release(s) by mouth twice a
day Disp #*28 Tablet Refills:*0
RX *morphine 15 mg 1 tablet extended release(s) by mouth twice a
day Disp #*28 Tablet Refills:*0
10. Polyethylene Glycol 17 g PO DAILY
11. Simethicone 80 mg PO TID:PRN gas, bloating
12. Famotidine 20 mg PO BID
13. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: s/p laminectomy
Secondary diagnoses: IBS, acute pain, constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your
hospitalization. You were admitted with a fever after your spine
surgery but were not found to have an infection. You were
constipated and given a bowel regimen. Your pain medications
were adjusted. You started to retain urine and a catheter was
placed. When we tried to have you urinate without the catheter,
you were unable to do so and the catheter was replaced. You
should follow up with the neurosurgeon 6 weeks after your
surgery and with the urologist to manage your catheter.
Followup Instructions:
___
|
10142207-DS-13 | 10,142,207 | 23,369,630 | DS | 13 | 2131-07-15 00:00:00 | 2131-07-15 16:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Status Epilepticus
Major Surgical or Invasive Procedure:
Endotracheal Intubation with successful extubation
History of Present Illness:
Mr. ___ is a ___ right-handed man with history of
seizure disorder, hypertension and depression who was
transferred from an outside hospital, intubated for multiple
seizures. At 5 a.m. yesterday, on ___, the patient woke
up and felt that he might have a seizure soon because he had the
urge to defecate, which often coincides with seizures. Because
he felt that he was going to have a seizure, the patient took an
extra 500 mg of
Depakote. Usually, he takes 500 mg 3 times per day, but that
morning, he took 1000 mg and he went back to sleep. At 7:30 in
the morning, he woke up again. He was not feeling well. He
felt confused and somewhat disoriented. He felt the urge to
defecate again and went to the bathroom. His wife said that he
was
grabbing at the toilet paper, but seemed "out of it." At that
time, his wife gave him another 500 mg of Depakote. So, by 7:30
in the morning, he had taken 1500 mg of Depakote. At 8:15, Mr.
___ had a seizure, which lasted about 20 seconds. His wife
states that his upper and lower extremities were both rigid
without any shaking. He did not bite his tongue or have urinary
incontinence. After the seizure ended, he was confused for
about ___ minutes. His wife also notes that prior to the
seizure, he made a yelping sound, which is typical before a
seizure for him. The patient then returned to his baseline. At
about 9 o'clock, he had another seizure. Again, his upper and
lower extremities were rigid without any jerks. The second
seizure lasted about 30 seconds and he was confused for 5
minutes. Again, no tongue
biting, no urinary incontinence. He then slept for about 4
hours. At 1 in the afternoon, he woke up and had another
seizure, same as the prior two. This one lasted about ___
minutes. He did bite his tongue and had urinary incontinence.
His wife called ___. By the time, EMS arrived, the seizure had
terminated on irs own. He was confused for the next ___ minutes
or so. In the ambulance, the patient had a generalized
tonic-clonic seizure. At that time, he was given 5 mg of IV
valium. When he arrived at ___ ED, he was agitated
and combative, so he was given another 5 mg of IV valium. Per
outside hospital documentation, this patient is reported to
often be combative and agitated when he is post ictal. They
attempted to obtain a non-contrast head CT. However, he was too
agitated for it. He was given another 5 mg of IV valium but
continued to be combative. At that time, he was intubated for
airway protection and given another 10 mg of IV valium. He was
also given 4 mg of IV Ativan, 1000 mg of fosphenytoin, 2 g of
ceftriaxone and then was maintained on propofol for sedation.
His valproic acid level at ___ was 97. He was
transferred to ___ for further evaluation. In the ambulance ride
on the way over, they ran out of propofol, so he was given 4 mg
of midazolam. In the ED here, he was minimally responsive even
off propofol, so no attempt was made at extubation, and he was
admitted to the neurologic ICU.
In the ED, he had a T-max of 101.6, which came down with
Tylenol. Overnight, there was concern for an infectious process.
He had an LP which showed 4 white cells and 3 RBCs. Prior to
results of CSF coming back, he was empirically started on
meningitis dosing of ceftriaxone 2 g, vancomycin and acyclovir
for HSV. He had a chest x-ray, which did not show pneumonia and
he had a UA which was negative for UTI. This morning, propofol
was turned off for
about ___ minutes and the patient woke up. He was quite
agitated; however, he was alert, awake and following commands.
The patient's wife ___ was present today to provide more
history. She said that Mr. ___ has had cold and has been
feeling unwell for the last week or so and on ___ had
subjective fevers and chills. He has not had a productive cough
and has not complained of dysuria or frequency of urination.
She said that at baseline, he drinks about ___ margaritas daily
but has not consumed any alcohol for the last several days in
the setting of feeling unwell.
In terms of his seizure history, he had his first seizure at
around age ___ or ___. He has only been treated with Depakote and
has not been tried on any other anti epileptics. His seizures
are quite well controlled and in the last ___ years, he has only
had 3 seizures. His last seizure was ___ year ago and was in the
setting of anti-epileptic drug noncompliance. Since then, he
has been taking his medications regularly. He does not ever
have myoclonic jerks and awakening or light sensitivity.
Past Medical History:
Seizure disorder, Hypertension, Depression
Social History:
___
Family History:
Has 5 siblings. None of them have seizure.
Parents did not have seizures. No family history of migraines,
stroke or MI.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 100.3 P: 95 R: 12 BP: 127/89 SaO2: 100% on 40%
oxygen
General: intubated, right after off propofol, patient can track
the voice, nod his head, but unable to follow up commands.
HEENT: ETT in place
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, ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: patient can track the voice, nod his head, but
unable to follow up commands.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 1.5 to 1mm and brisk.
III, IV, VI: unable to test
V: unable to test
VII: unable to assess with ETT in place
VIII: unable to assess
IX, X: per nursing report, gag intact
XI:unable to asess
XII: unable to assess with ETT in place
-Motor: Normal bulk, tone throughout. Spontaneous movement of
bilateral upper extremities and lower extremities.
-Sensory: withdraws somewhat to pain
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 0
R 1 1 1 1 0
Plantar response was mute bilaterally.
-Coordination: unable to assess
-Gait: Deferred
DISCHARGE EXAM:
***************
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, fluent language with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt. was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. 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. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 1 1 2 1
R 2 1 1 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Per ___ - Good initiation. Narrow-based, normal stride
and arm swing. Able to walk in tandem without difficulty.
Pertinent Results:
Labs on Admission:
___ 05:00AM BLOOD WBC-7.8 RBC-4.09* Hgb-12.8* Hct-38.0*
MCV-93 MCH-31.4 MCHC-33.8 RDW-13.0 Plt ___
___ 05:00AM BLOOD Plt ___
___ 05:00AM BLOOD Glucose-95 UreaN-7 Creat-0.9 Na-139 K-3.8
Cl-101 HCO3-30 AnGap-12
___ 09:35AM BLOOD CK(CPK)-9452*
___ 05:00AM BLOOD CK(CPK)-7728*
___ 05:00AM BLOOD CK-MB-11* MB Indx-0.3 cTropnT-0.03*
___ 09:35AM BLOOD cTropnT-0.02*
___ 02:03AM BLOOD Albumin-3.9 Calcium-8.2* Phos-2.4* Mg-1.9
___ 09:35AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.9
___ 05:00AM BLOOD Valproa-51
___ 02:03AM BLOOD Phenyto-5.0* Valproa-78
___ 06:27AM BLOOD Lactate-2.6*
___ 09:13PM BLOOD Glucose-96 Lactate-3.7* Na-133 K-6.0*
Cl-98 calHC___
Imaging/Studies:
CT head w/o contrast ___
FINDINGS: There is no evidence of infarction, hemorrhage,
discrete masses, mass effect or shift of normally midline
structures. The ventricles and sulci are normal in size and
configuration.
Bilateral mastoid air cells are clear. There are mucosal
secretions within the sphenoid sinus as well the nasal cavity,
likely representing intubation. There is mucosal thickening
involving bilateral maxillary sinuses. The globes are intact.
IMPRESSION:
1. No evidence of hemorrhage or infarction.
2. Mucosal thickening involving the sphenoid and maxillary
sinuses as well as secretions within the nasal cavity likely
representing intubation.
EEG Read (ICU) - This telemetry captured no pushbutton
activations. The initial diffuse beta activity and background
suppression indicate moderate to severe encephalopathy which was
possibly due to medication effect, e.g. propofol, or
benzodiazepine. During the later half of the recording, the
waking background was improved to ___ Hz indicating mild
encephalopathy. There were no electrographic seizures or
epileptiform discharges.
Brief Hospital Course:
Mr. ___ is a ___ right handed man with history of
seizure disorder, hypertension and depression who was
transferred from an outside hospital, intubated and sedated
after having multiple seizures.
# Neuro:
Patient had 4 seizures the day of admission--3 tonic seizures at
home and 1 GTCs on ambulance ride to the hospital. At OSH, he
was loaded with dilantin prior to transfer. Per patient's wife,
he had an upper respiratory tract infection for the last week
with subjective fevers and chills. Infectious work up was
negative for pneumonia, urinary tract infection, meningitis (see
below). He has been compliant with his medications. Of note,
the patient usually drinks ___ margaritas daily but has not
consumed any alcohol for the last several days. Most likely his
seizure was triggered by infection versus alcohol withdrawal.
So, we did not feel there as a need to obtain further brain
imaging with an MRI at this time or to adjust his home
anti-epileptics. He was on long term EEG monitoring and did not
have any epileptiform activity. Dilantin was tapered off slowly
and he was continued on his home dose of Depakote 500mg Delayed
Release PO BID.
# Cardiac: Was monitored on telemetry and did not have any
abnormal rhythms. Continued home metoprolol and lisinopril.
Due to BP increases to 180s, Hydralazine IV was administered
with good effect. Of note the BP increases were in the setting
of likely alcohol withdrawl given his history of ___ hard liquor
drinks per day for a considerable period. CIWA protocol was
initiated and his lisinopril was increased to 30mg qDay with
good effect ___ SBP for the remainder of his
hospitalization.
# ID: Patient had a temperature to 101.6 in the ED. He was
emperically started on Vancomycin/Ceftriaxone/Acyclovir in
meningitis dosing. Chest x-ray with no pneumonia. UA with no
UTI. CSF without elevated WBC or RBCs. No source of infection.
Leukocytosis most likely in the setting of seizure and and
trended down to normal. Discontinued all antibiotics.
# Pulmonary: Was intubated prior to transfer. Extubated without
difficulty.
# RENAL: Cr was 1.3 on admission and CK peaked at ~9000. In
setting of mild rhabdo after seizure. CK trended down with
hydration.
# PSYCH: Social work was consulted on Mr. ___ for the
concern for alcohol withdrawl during his time out of the ICU
which was approximately ___ days after his last drink where he
was noted to be diaphoretic, had increased blood pressure, and
some tremor. He was placed on CIWA protocol which improved his
symptoms considerably with blood pressures decreased to 140 from
180s. Social work noted there was no bed available for
inpatient alcohol rehab which prompted us to offer the patient
the option of taking a short course of ativan home for
prophylaxis against withdrawl symptoms. The patient agreed to
not drink over the course of the four days between discharge and
presentation to the ___ rehabilitation.
TRANSITIONS OF CARE:
-Code status: Full code
Medications on Admission:
- Depakote Delayed Release 500 mg bid
- Metoprolol-XL 100 mg daily
- Citalopram 40 mg daily
- Lisinopril 20 mg daily
Discharge Medications:
1. Divalproex (DELayed Release) 500 mg PO BID
first now
2. Metoprolol Succinate XL 100 mg PO DAILY
Hold sbp <100, hr <60
3. Azithromycin 250 mg PO Q24H
Please take 2 pills the first day, then 1 pill each day for the
following 4 days.
RX *azithromycin 250 mg ___ tablet(s) by mouth daily Disp #*6
Tablet Refills:*0
4. Guaifenesin ___ mL PO Q6H:PRN sore throat / cough
RX *guaifenesin 100 mg/5 mL ___ tablespoons by mouth every six
(6) hours Disp #*1 Bottle Refills:*0
5. Citalopram 40 mg PO DAILY
6. Lorazepam 1 mg PO Q4H:PRN sweating, palpations Duration: 4
Days
RX *lorazepam 1 mg 1 tablet(s) by mouth every four (4) hours for
the first day, then at most every 6 hours for day 2, then at
most every 8 hours for days ___ Disp #*24 Tablet Refills:*0
7. Lisinopril 30 mg PO DAILY
hold sbp <100
RX *lisinopril 30 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Status Epilepticus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the ICU ___
___ seizures which lasted an abnormal length of time,
known as status epilepticus. On admission, you were intubated
for protection of your airway; with improvement of your
condition, we were able to extubate you safely. You were
further monitored in our ICU then general floor with continuous
EEG which did not show any seizures or
epileptiform discharges.
Please continue your Depakote Delayed Release twice a day as
prescribed. You have also been prescribed medications to treat
your sinus infection. Please complete your course of antibiotic
treatment and follow up with your PCP next week.
You were also provided information for alcohol cessation
services and a course of medication to help bridge your care
from here to rehabilitation services. Please take this
medication as necessary for the next four days. It is
IMPERATIVE that you do not drink alcohol while on this
medication.
Followup Instructions:
___
|
10142207-DS-14 | 10,142,207 | 27,739,425 | DS | 14 | 2136-04-01 00:00:00 | 2136-04-01 18:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a ___ right-handed man with history of
generalized epilepsy, well controlled on lamotrigine
monotherapy,
followed by ___ neurology, hypertension, who presents
for
multiple breakthrough seizures in the past 2 days. History is
obtained from girlfriend at bedside.
She reports that the patient was last seen in his usual state of
health 2 evenings ago. Yesterday morning, she left home early
for work and when she came back at noon, she found him at home,
disoriented and confused. She states he has had similar
episodes
in the past. She gave him a dose of oral Ativan as well as
lamotrigine, and he slowly improved back to normal state. Then
at 4 ___ he had what she calls a "small seizure", described as
generalized twitching lasting less than 1 minute. He was poorly
responsive for half an hour and then returned to his normal
state. Then at 6:30 ___, he had a "grand mal" seizure,
consisting
of generalized convulsions, lasting <5 minutes, with associated
tongue biting. Afterwards, he was very somnolent and
unresponsive. She gave him a second dose of Ativan and
lamotrigine, which she placed under his tongue. Over the next
several hours, he appeared to slowly improve, and by 10 ___ he
was
patting and speaking to the dog, and he fell asleep on the
couch.
His girlfriend went to sleep in the bedroom.
Then this morning at 5 AM, she was awoken by commotion in the
living room and walked over to find the patient in the midst of
another generalized convulsive seizure, which lasted again <5
minutes. This time she called ___, and EMS arrived and brought
him to ___. There he was awake but unable to speak
or
interact with staff, and he was given a dose of Ativan without
relief. He was subsequently transferred to ___ ED for further
evaluation.
here, he has slowly started to speak more in 1 word answers such
as yes/no, however she still appears extremely confused, per
girlfriend. She denies him reporting any unusual symptoms in
the
past few days, such as fever, chills, night sweats, nausea,
vomiting, diarrhea, chest pain, cough, or shortness of breath.
Of note, he has been complaining of nasal congestion and eye
swelling due to allergies, which apparently has triggered
seizures in the past. She reports he has good medication
compliance. He does drink alcohol, ___ rum cocktails daily.
His seizure history started in his teenage years, and he was
initially treated with Depakote, and at some point switched to
Lamictal. He has average of 1 breakthrough seizures per year,
usually in the setting of an infection, medication
noncompliance,
or alcohol withdrawal. He was admitted to ___ once in ___ for
a series of breakthrough seizures requiring propofol and
intubation which was felt attributable to alcohol
use/withdrawal.
Past Medical History:
Seizure disorder, Hypertension, Depression
Social History:
___
Family History:
Has 5 siblings. None of them have seizure.
Parents did not have seizures. No family history of migraines,
stroke or MI.
Physical Exam:
Admission exam:
Vitals: ___ 20 94% RA
General: Awake, easily distractible, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: supple, no nuchal rigidity
Pulmonary: no increased work of breathing
Cardiac: tachycardic, regular rhythm
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: no C/C/E bilaterally
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: Alert, regards and smiles at examiner. Answers
in
___ word answers such as yes/no, occasional phrases. Able to
state own name but not location or date (answers "yes"). Can
name
thumb and knuckles, but not watch or pen. Unable to repeat.
Follows some simple commands, such as protruding tongue and
raising extremities, but unable to close eyes or follow 2-step
commands or distinguish left-right. Easily distractible to
objects around him.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact grossly.
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. Slight postural tremor noted in L>R upper
extremities. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5
-Sensory: Withdraws to noxious stimuli bilaterally, unable to
formally test. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor bilaterally.
-Coordination: Mild postural tremor R>L. No dysmetria on
reaching
out to touch objects.
-Gait: Deferred.
Discharge exam:
General: Awake, nad
HEENT: NC/AT
Neck: supple, no nuchal rigidity
Pulmonary: no increased work of breathing
Cardiac: tachycardic, regular rhythm
Abdomen: soft, NT/ND
Extremities: no C/C/E bilaterally
Skin: no rashes or lesions noted
neuro:alert and oriented to person and place, thought it was ___, language fluent, no dysarthria, he had persistent
attentional problems, substantial encoding difficulties, and
retrieval memory problems. He also has phonemic paraphrases
error.
PERRL, EOMI, face symmetric, strength ___ throughout, sensation
intact throughout
Pertinent Results:
___ 12:20PM GLUCOSE-123* UREA N-15 CREAT-1.2 SODIUM-137
POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-21* ANION GAP-21*
___ 12:20PM estGFR-Using this
___ 12:20PM ALT(SGPT)-28 AST(SGOT)-33 ALK PHOS-82 TOT
BILI-0.9
___ 12:20PM ALBUMIN-5.1 CALCIUM-10.1 PHOSPHATE-2.3*
MAGNESIUM-2.1
___ 12:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 12:20PM WBC-15.6*# RBC-4.90 HGB-15.5 HCT-45.3 MCV-92
MCH-31.6 MCHC-34.2 RDW-12.7 RDWSD-43.1
___ 12:20PM NEUTS-78.1* LYMPHS-8.4* MONOS-12.4 EOS-0.3*
BASOS-0.4 IM ___ AbsNeut-12.17* AbsLymp-1.31 AbsMono-1.93*
AbsEos-0.04 AbsBaso-0.06
___ 12:20PM PLT COUNT-283
cvEEG:
Prelim-cvEEG showed initial slowing but quick improvement
without any epileptiform activity
Brief Hospital Course:
Mr. ___ is a ___ right-handed man with history of
generalized epilepsy, well controlled on lamotrigine
monotherapy,
followed by ___ neurology, hypertension, who presented
for
multiple events consistent with breakthrough seizures in the
past
2 days. He underwent cvEEG which showed initial slowing but
quick improved without any epileptiform activity. The etiology
of his breakthrough seizures is not entirely clear at this time;
there is no evidence of medication noncompliance or decreased
absorption, metabolic derangements, or underlying infection. In
addition, pt denied any changes in alcohol intake. He does
endorse a hx of seizure during the ___, which he attributes
to seasonal allergies. His outpatient neurologist confirmed that
his last seizure was in the ___ and was attributed to
allergies in addition to maybe missed medication dose.
Furthermore, on exam pt was noted to have significant cognitive
problems, including persistent attentional problems, substantial
encoding difficulties, retrieval memory problems, as well as
phonemic paraphrases error. This is concerning for possible
bilateral mesotemporal problems with left lateralization. He
needs close follow up with his outpatient neurologist for
further w/u, starting with revaluation in about a week to assess
possible post-ictal contribution that may clear. If he continues
to have persistent cognitive problems he would benefit from MRI
brain. He has follow up with his outpatient neurologist next
week. He also has an appointment with cognitive neurology here
at ___. He was discharged home in stable condition. No changes
to his medications were made.
Transitional issues:
-revaluation in about a week to assess possible post-ictal
contribution to
cognitive problem, if not cleared by next week, pt will need
MRI brain for
further assessment.
-lamicatal level
-Neurology follow up
-Neuro Cognitive clinic follow up
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. amLODIPine 5 mg PO DAILY
2. LamoTRIgine 200 mg PO BID
3. Gabapentin 300 mg PO QHS
4. Lisinopril 20 mg PO DAILY
5. LORazepam 1 mg PO Q4H:PRN seizure
6. Citalopram 40 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Vitamin D Dose is Unknown PO Frequency is Unknown
9. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Vitamin D 1000 UNIT PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Citalopram 40 mg PO DAILY
4. Gabapentin 300 mg PO QHS
5. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
6. LamoTRIgine 200 mg PO BID
7. Lisinopril 20 mg PO DAILY
8. LORazepam 1 mg PO Q4H:PRN seizure
9. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for increased seizures. You underwent
an EEG which initially showed some slowing but quickly improved.
No changes to your medications were made. We believe the trigger
for your seizure was due to seasonal allergies.
Please take your medications as prescribed. Please follow up
with your PCP as below.
It was a pleasure taking care of you,
Best,
Your ___ care team
Followup Instructions:
___
|
10142213-DS-2 | 10,142,213 | 25,711,897 | DS | 2 | 2163-11-14 00:00:00 | 2163-11-14 11:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PODIATRY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Left Foot (hallux) osteomyelitis
Major Surgical or Invasive Procedure:
___:
Left Hallux open amputation with wound VAC placement
___: bedside closure of L hallux amputation site
History of Present Illness:
___ with DM presenting to the ED with c/o L hallux infection /
pain. He states that for a little over a week he had noticed
increased redness, swelling, and pain to the L hallux. He was
seen at ___ and placed on indomethacin due to
c/f gout in the L hallux. The toe did not improve. He presents
for further evaluation of the toe and infection. He states that
his blood glucose levels have not been well controlled lately.
He just recently started to be followed by ___. He denies any
recent n/v/f/c/cp/sob/back pain.
Past Medical History:
PMH:
DM
Hemachromatosis
PSH: multiple neck sx (C5/C6/T1), multiple L knee surgeries /
scopes, L hand injury and repair, R shoulder injury with labral
and bicep repair.
Social History:
___
Family History:
NC
Physical Exam:
On Admission:
VITALS: 97.6 106 117/63 18 99% RA
GEN: NAD, AOx3
RESP: CTA, no respiratory distress
CV: RRR
ABD: soft, ___ FOCUSED EXAM: palpable ___ pulses b/l. cap refill <3 sec to
the digits. Mild edema to the L foot. Erythema and warmth to the
L foot from the hallux extending up the dorsal foot. necrotic
area to the dorsal aspect of the L hallux. Pain with palpation
of the L hallux and forefoot.
NEURO: light touch sensation intact to the ___.
On Discharge:
VITALS: AVSS
GEN: NAD, AOx3
RESP: CTA, no respiratory distress
CV: RRR
ABD: soft, ___ FOCUSED EXAM: palpable ___ pulses b/l. cap refill <3 sec to
the digits. Dry sterile dressing in place.
Pertinent Results:
On Admission:
___ 03:05PM BLOOD WBC-8.0 RBC-4.03* Hgb-12.4* Hct-36.8*
MCV-91 MCH-30.8 MCHC-33.7 RDW-12.3 RDWSD-41.3 Plt ___
___ 03:05PM BLOOD Neuts-73.0* Lymphs-14.9* Monos-10.0
Eos-0.8* Baso-0.4 Im ___ AbsNeut-5.84 AbsLymp-1.19*
AbsMono-0.80 AbsEos-0.06 AbsBaso-0.03
___ 03:05PM BLOOD ___ PTT-31.9 ___
___ 03:05PM BLOOD Glucose-271* UreaN-15 Creat-0.9 Na-134
K-4.8 Cl-96 HCO3-28 AnGap-15
___ 12:45PM BLOOD Calcium-8.6 Phos-2.3* Mg-1.8
___ 12:45PM BLOOD CRP-71.2*
___ 03:25PM BLOOD Lactate-1.3
.
Other Pertinent:
___ 12:45PM BLOOD %HbA1c-8.9* eAG-209*
.
On Discharge:
.
Imaging:
Left Foot Xray ___: Cortical destruction of the first digit
distal phalanx worrisome for acute osteomyelitis. Associated
soft tissue gas in the big toe.
Left Foot Xray ___: There has been interval amputation of the
great toe at the level of the proximal base of the proximal
phalanx. Wound VAC projects over the surgical site. There is a
large posterior calcaneal spur.
.
PATHOLOGY:
Pathology Report Tissue: TOES, AMPUTATION, NON-TRAUMATIC
Procedure Date of ___
Report not finalized.
Assigned Pathologist ___, MD
___ in only.
PATHOLOGY # ___
TOES, AMPUTATION, NON-TRAUMATIC
.
Microbiology:
****
Time Taken Not Noted Log-In Date/Time: ___ 8:49 am
TISSUE LEFT HALLUX .
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
TISSUE (Preliminary):
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
in this
culture.
ANAEROBIC CULTURE (Preliminary):
Brief Hospital Course:
The patient was admitted to the podiatric surgery service from
the ED on ___ for an acute bone infection of the Left Foot
Big toe. On admission, he was started on broad spectrum
antibiotics. On ___ he was taking to the OR for left hallux
amputation which was left open and a wound VAC placed to the
surgical site. 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. He was placed on
vancomycin, ciprofloxacin, and flagyl while hospitalized and
discharged with *****. His intake and output were closely
monitored and noted to be adequtae. The patient received
subcutaneous heparin throughout admission; early and frequent
ambulation were strongly encouraged.
On ___ to L hallux amputation site was closed bedside with a
dry sterile dressing placed.
The patient was subsequently discharged to home on POD 5 with PO
abx and ___ . 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. OxyCODONE (Immediate Release) 20 mg PO Q6H
2. MetFORMIN (Glucophage) 500 mg PO BID
3. Atorvastatin 40 mg PO QPM
4. Aspirin 81 mg PO DAILY
5. Glargine 6 Units Breakfast
Glargine 6 Units Bedtime
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*1
3. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*14 Capsule Refills:*0
4. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth q 8 hours Disp
#*30 Tablet Refills:*0
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Glargine 6 Units Breakfast
Glargine 6 Units Bedtime
8. MetFORMIN (Glucophage) 500 mg PO BID
9. OxyCODONE (Immediate Release) 20 mg PO Q6H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left Foot (Hallux) osteomyelitis
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 on ___ for treatment of a
bone infection in your Left Foot. You were given IV antibiotics
while here. You are being discharged with the following
instructions:
ACTIVITY:
There are restrictions on activity. Please remain weight bearing
to your heel only on the Left 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:
___
|
10142213-DS-3 | 10,142,213 | 27,416,132 | DS | 3 | 2164-03-22 00:00:00 | 2164-03-25 19:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Progressive left foot erythema and edema c/f cellulitis and a
progressive necrotic left second toe
Major Surgical or Invasive Procedure:
Amputation of left ___ toe.
History of Present Illness:
___ s/p amputation left great toe with podiatry in ___ who
subsequently developed an ulcer on the left second toe and was
found to have severe tibial disease on non-invasives, thus
underwent angiogram with PTA of distal SFA and popliteal artery
at the level of the knee joint. The patient reports that post
angiogram and PTA, his toe ulcer became gangrenous. He has been
evaluated by podiatry between and this intervention and his
current presentation, and he reports much improvement recently.
However, he was doing well enough that he tried to wear sneakers
in order to prepare for returning to work. After removing his
sneakers he found his foot to be edematous and painful. The next
day he noted new erythema. He wrapped the gangrenous toe and the
rest of the foot for 2 days, and after removing the wrap today
he noticed spreading erythema to the midfoot. He reports
worsening pain in his left foot, which he also reports is warm
to the touch. He denies new discharge from the gangrenous site.
Denies fevers/chills, chest pain, shortness of breath, or
dysuria.
Past Medical History:
PMH:
DM
Hemachromatosis
PSH: multiple neck sx (C5/C6/T1), multiple L knee surgeries /
scopes, L hand injury and repair, R shoulder injury with labral
and bicep repair.
Social History:
___
Family History:
NC
Physical Exam:
General: well appearing, well nourished, in no distress.
Head: normocephalic, atraumatic, no visible or palpable masses.
Heart: RRR
Lungs: Clear to auscultation and percussion
Abdomen: Bowel sounds normal, no tenderness, nondistended
Extremities: Amputation of Left ___ toe. Wound closed with
interrupted sutures. Adequate healing without evidence of
infection (erythema, swelling, or discharge). Left foot covered
by Xeroform followed by fluffs and Kerlix. S/p hallux amputation
on same side with well healed surgical site.
Neuro: CN ___ intact.
Brief Hospital Course:
Prepared by: ___, Medical Student (Approved by ___
___, PGY1, Surgery)
Mr. ___ is a ___ diabetic smoker who presented to the ED on
___ with progressive left foot erythema and edema c/f
cellulitis and a progressive necrotic left second toe. The
patient was admitted to the Vascular Surgery service and found
to
require amputation of the necrotic toe and IV antibiotics for
his
cellulitis. His amputation occurred the following day on
___ without complications. Standard wound care protocols
were followed s/p left second toe amputation until his discharge
on ___ with application of Xeroform followed by fluffs
and Kerlix.
His cellulitis was treated with IV antibiotics (cipro, vanco). A
tissue and wound culture were taken during the amputation which
came back negative upon gram stain analysis and culture results
are pending. He was informed that he should report to the ED if
nay signs of infection present themselves including fever,
swelling, discharge, etc.
During his recovery in the vascular service he experienced
multiple episodes of bilious emesis and intermittent nausea
refractory to antiemetics but Mr. ___ discloses he's been
having such events for the past 7months stemming from his DM. He
was advised to f/u with his ___ providers as an outpatient
re:
these symptoms.
He was discharged home with ___ on ___ ___valuation. He was discharged on his normal chronic pain
medications (oxycodone), antibiotics (Bactrim) and his normal
home meds.
Medications on Admission:
1. Atorvastatin 40 mg tablet
2. Clopidogrel 75 mg tablet
3. Humalog KwikPen 100 unit/mL subcutaneous (6 twice a day with
breakfast/dinner)
4. Metformin 500 mg tablet BID
5. Ondansetron HCl 8 mg tablet q8hr PRN nausea
6. Oxycodone 20 mg tablet 1 tab q6hr PRN pain
7. Aspirin 81 mg chewable tablet
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. LORazepam 0.5 mg PO QHS:PRN insomnia Duration: 5 Days
RX *lorazepam 0.5 mg 1 tablet(s) by mouth at bedtime Disp #*5
Tablet Refills:*0
3. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth twice a day Disp #*14 Tablet Refills:*0
4. Atorvastatin 40 mg PO QPM
5. Humalog 6 Units Breakfast
Humalog 6 Units Dinner
Insulin SC Sliding Scale using REG Insulin
6. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Gangrenous ___ toe, s/p left ___ toe amputation
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 ___ and
underwent an amputation of your left second toe. You have now
recovered from surgery and are ready to be discharged. Please
follow the instructions below to continue your recovery:
ACTIVITY:
On the side of your amputation you are non weight bearing for
___ weeks. It is very important to follow this.
You should keep this amputation site elevated whenever
possible.
You may use the opposite foot for transfers and pivots.
No driving until cleared by your Surgeon.
No heavy lifting greater than 20 pounds for the next 3 weeks.
BATHING/SHOWERING:
You may shower when you get home
No tub baths or pools / do not soak your foot for 4 weeks from
your date of surgery
WOUND CARE:
Sutures / Staples may have been removed before discharge. If
they are not, an appointment will be made for you to return for
staple removal.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
CAUTIONS:
If you smoke, please make every attempt to quit. Your primary
care physician can help with this. Smoking causes narrowing of
your blood vessels which in turn decreases circulation.
DIET:
Low fat, low cholesterol / if you are diabetic follow your
dietary restrictions as before
CALL THE OFFICE FOR: ___
Bleeding, redness of, or drainage from your foot wound
New pain, numbness or discoloration of the skin on the
effected foot
Fever greater than 101 degrees, chills, increased redness, or
pus draining from the incision site.
Followup Instructions:
___
|
10142213-DS-6 | 10,142,213 | 20,154,856 | DS | 6 | 2164-09-15 00:00:00 | 2164-09-16 09:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Left lower extremity pain, pulselessness
Major Surgical or Invasive Procedure:
___ Left lower extremity diagnostic angiogram
___ Left superficial femoral artery thrombectomy, patch
angioplasty, popliteal artery thrombectomy
History of Present Illness:
Mr. ___ is a ___ old man with h/o PAD s/p recent
resection for ___ metatarsal head-on the left and LLE angiogram
with L SFA stent placement (___), who now presents with
a cold, pulseless, L foot. He states that he began to have pain
in the left foot since noon on ___, and subsequently came in
today because his pain was unbearable. He describes this as a
burning sensation. He has lost sensation in the foot, and notes
that it is very pale and cool. He does also note the it is
extremely swollen up to the level of the ankle. He has been
unable to ambulate on the foot due to pain.
Past Medical History:
PAD
DM
Hemachromatosis
PSH: Left great toe amp (___), left ___ toe amp (___), L
SFA stent ___, multiple neck sx (C5/C6/T1), multiple
L knee surgeries / scopes, L hand injury and repair, R shoulder
injury with labral and bicep repair. L
Social History:
___
Family History:
Non-contributory
Physical Exam:
Discharge Physical Exam:
T:98.2 PO BP:137/71 HR:94 RR:18 O2 sat: 98% Ra
Gen:NAD
CV: RRR
Resp: No resp distress
Abdomen: abdomen soft, non-distended, appropriately tender to
palpation
Ext: warm and well perfused
Wounds: L ___ incisions clean/dry/intact, L foot chronic
incisional wound/scar intact, abdominal incision partly open
without purulent drainage or surrounding erythema
R: P//D/P L: P//D/D (peroneal dopplerable)
Pertinent Results:
ADMISSION LABS:
___ 07:18PM BLOOD ___ PTT-28.3 ___
___ 07:18PM BLOOD Glucose-167* UreaN-15 Creat-0.6 Na-135
K-4.7 Cl-94* HCO3-29 AnGap-12
IMAGING:
___ CTA bilateral lower extremities with runoff
IMPRESSION:
1. Occlusion of the left superficial femoral artery, just
proximal to the known stent, which is also occluded. There is
reconstitution at the left popliteal artery. There is a delayed
2 vessel runoff on the left, with attenuation of the left
peroneal artery, as detailed above. The left dorsal and plantar
arches are not opacified on this study.
2. Slight delay in the three-vessel runoff of the right lower
extremity.
3. Incidental asymmetric thickening along the anterior right
abdominal wall, with a superficial surgical clip. This could
possibly represent a hematoma, but is incompletely imaged.
Please correlate for appropriate history.
___ Lower extremity vein mapping
FINDINGS: Duplex evaluation was performed of both lower
extremity superficial veins. Neither small saphenous vein is
suitable conduit. Left greater saphenous vein is patent but
multiple areas where the wall is thick consistent with
phlebitis. Right greater saphenous vein is patent with diameters
ranging from 0.21 -.49.
Venous mapping study as above only suitable conduit is the right
greater saphenous vein the specially in the upper portion.
___ Upper extremity vein mapping
FINDINGS: Doppler evaluation was performed of both upper
extremity superficial venous system. The right cephalic vein is
patent in the upper arm, it is thick walled proximally.
Basilic vein has a similar pattern on the right. On the left
there is thrombus in the cephalic vein. Basilic vein is patent.
___ ABIs/PVRs
FINDINGS: On the right side, triphasic Doppler waveforms were
seen at the right femoral,
popliteal, posterior tibial and dorsalis pedis arteries. The
right ABI is 1.15 at rest. On the left side, triphasic Doppler
waveforms were seen at the left femoral and popliteal arteries.
There are monophasic waveforms within the posterior tibial and
dorsalis pedis arteries. Left toe pressures were not obtained
due to prior great toe amputation. The left ABI is 0.72 at
rest. Pressure volume recordings were not obtained of the left
calf or thigh due to staples. Amplitudes were otherwise within
normal limits.
IMPRESSION: Moderate tibial and distal arterial insufficiency of
the left lower extremity as demonstrated by monophasic waveform
within the posterior tibial and dorsalis pedis arteries and a
diminished ankle brachial index of 0.72.
Brief Hospital Course:
Mr. ___ is a ___ year old male with a history of peripheral
vascular disease s/p left superficial femoral artery stenting
who was admitted to the ___ on
___ with acute on chronic ischemia of the left lower
extremity secondary to stent occlusion. He was started on a
heparin drip immediately. The patient was then taken to the
endovascular suite and underwent left lower extremity diagnostic
angiogram. For details of the procedure, please see the
surgeon's operative note. The patient tolerated the procedure
well without complications and was brought to the
post-anesthesia care unit in stable condition.
The patient subsequently underwent vein mapping in preparation
for possible left lower extremity bypass surgery. He was taken
to the operating room on ___ and underwent left superficial
femoral and artery thrombectomy with stent removal and patch
angioplasty as well as popliteal artery thrombectomy. For
details of the procedure, please see the surgeon's operative
note. The patient tolerated the procedure well without
complications and was brought to the post-anesthesia care unit
in stable condition. After a brief stay, the patient was
transferred to the vascular surgery floor where he remained
through the rest of the hospitalization.
Post operatively, the patient's heparin drip was resumed. He
regained doppler signals in his left foot. Repeat ABIs/PVRs
demonstrated improved blood flow to the metatarsal level on his
left lower extremity. He was later transitioned to ___ for
planned 1 month course of anticoagulation to maintain left lower
extremity vessel patency. He worked with physical therapy who
recommended home with nursing and physical therapy services.
His hospital course was complicated by poor pain control in the
setting of chronic narcotic use. The acute pain and chronic pain
services were consulted for assistance in managing the patient's
pain. The patient also developed significant erythema purulent
drainage from his abdominal incision from his recent open
cholecystectomy. Given concern for a surgical site infection,
ACS service was asked to re-evaluate this wound and they removed
some skin staples. He was treated with a 5 day course of
antibiotics and daily wet to dry dressing changes. The drainage
decreased and cleared such that it was no longer purulent.
On ___, the patient was able to tolerate a regular diet,
get out of bed and ambulate without assistance, void without
issues, and pain was controlled on oral medications alone. He
was deemed ready for discharge, and was given the appropriate
discharge and follow-up instructions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
7. Gabapentin 200 mg PO TID
8. OxyCODONE (Immediate Release) 20 mg PO Q6H:PRN Pain -
Moderate
9. LORazepam 0.25-0.5 mg PO Q4H:PRN anxiety
10. Clopidogrel 75 mg PO DAILY
Discharge Medications:
1. OxyCODONE SR (OxyconTIN) 20 mg PO Q8H hold for sedation
RX *oxycodone [OxyContin] 20 mg 1 tablet(s) by mouth every eight
(8) hours Disp #*20 Tablet Refills:*0
2. Rivaroxaban 15 mg PO BID Duration: 3 Weeks
3. Rivaroxaban 20 mg PO DAILY Duration: 1 Week
Complete the 3 week course of 15mg twice daily first, then begin
taking 20mg daily.
4. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Docusate Sodium 100 mg PO BID
9. Gabapentin 200 mg PO TID
10. LORazepam 0.25-0.5 mg PO Q4H:PRN anxiety
11. MetFORMIN (Glucophage) 500 mg PO BID
12. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: arterial thrombosis, peripheral vascular disease
Secondary: chronic pain, anxiety, diabetes, abdominal wound
infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for
acute on chronic ischemia of the left lower extremity. He
underwent left lower extremity diagnostic angiogram followed by
open revascularization of the left lower extremity including
removal of your prior stent. You have now recovered from surgery
and are ready to be discharged. Please follow the instructions
below to continue your recovery:
WHAT TO EXPECT:
1. It is normal to feel tired, this will last for ___ weeks
You should get up out of bed every day and gradually increase
your activity each day
You may walk and you may go up and down stairs while wearing
your off-loading shoe.
Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
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
3. It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some
weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
MEDICATION:
Take aspirin and Xarelto as instructed
Follow your discharge medication instructions
ACTIVITIES:
No driving until post-op visit and you are no longer taking
pain medications
Unless you were told not to bear any weight on operative foot:
You should get up every day, get dressed and walk
You should gradually increase your activity
You may up and down stairs, go outside and/or ride in a car
Increase your activities as you can tolerate- do not do too
much right away!
No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
CALL THE OFFICE FOR: ___
Redness that extends away from your incision
A sudden increase in pain that is not controlled with pain
medication
A sudden change in the ability to move or use your leg or the
ability to feel your leg
Temperature greater than 100.5F for 24 hours
Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Thank you for allowing us to participate in your care!
Sincerely,
Your ___ team
Followup Instructions:
___
|
10142404-DS-17 | 10,142,404 | 22,811,313 | DS | 17 | 2157-02-08 00:00:00 | 2157-02-11 09:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
codeine
Attending: ___.
Chief Complaint:
RLE Pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ male with history of HIV (CD4 count greater than
500, viral load undetectable) presents with erythema and pain of
the right lower extremity. Pt reports he was in his USOH until 3
days prior to admission when he began experiencing RLE pain. Per
ED report, states he noticed a cut on his right foot 2 days ago,
but is unsure how he got it. Patient noticed rash on RL that
gradually worsened until today, the associated pain made it
difficult to ambulate, at which time he called an ambulance.
In the ED, initial vital signs were: 98.0 91 115/76 18 96%RA
- Exam notable for: erythematous rashes on b/l ___
- Labs were notable for normal CBC, chem panel and lactate
- Studies performed include RLENIs which were negative on
preliminary read
- Patient was given 1 L NS, Vancomycin 1 g IV,
Oxycodone-Acetaminophen ___ mg PO, Morphine 5 mg IVx1
Upon arrival to the floor, the patient answered questions in a
slow, lethargic voice. Appears comfortable, still asking for
pain medication. Denies N/V/F/C/SOB. Reports otherwise feeling
well. Upon interview with senior assistant resident, pt admits
to recent heroin overdose requiring hospitalization at ___
___. Reports last using 2 days ago.
Past Medical History:
HIV
Chronic hepatitis C
Opioid dependence
Anxiety
Tobacco dependence
Likely COPD but hasn't yet had PFTs
Surgical History
appendectomy childhood
pins in R hand ___
Social History:
___
Family History:
Per ___ record:
Father: deceased, died of MI age ___, diagnosed with CAD
Mother: deceased, hx of smoking, had copd and died from
complications of that, diagnosed with CAD
Siblings: deceased, brother died of lung CA, diagnosed with CA
Children: alive, one daughter has a "muscle problem," other
daughter is in good health.
Physical Exam:
ADMISSION:
Vitals: 97.3 100/65 74 16 100%
General: Middle aged man laying comfortably in hospital bed with
slowed somewhat slurred speech
HEENT: NCAT EOMI MMM
Neck: Supple, full ROM, no cervical LAD
CV: S1/S2 RRR No M/R/G
Lungs: CTAB
Abdomen: +BS soft NT/ND
GU: No CVA tenderness
Ext: RLE: tender erythematous and warm 6 cm circumpherentially
along lower shin, R foot has tender erythematous area with
overlying healed cut between ___ and ___ phalanx LLE: Smaller, 3
cm circumpherential rash along lower shin
Neuro: AAOx3
Skin: Otherwise, skin warm, dry
DISCHARGE:
VSS
General: Middle aged man laying comfortably in hospital bed with
slowed somewhat slurred speech
HEENT: NCAT EOMI MMM
Neck: Supple, full ROM, no cervical LAD
CV: S1/S2 RRR No M/R/G
Lungs: CTAB
Abdomen: +BS soft NT/ND
GU: No CVA tenderness
Ext: Vastly improved erythema, tenderness b/l shins--largely
resolved. RLE foot mild 1-2 cm of erythema remain.
Neuro: AAOx3
Skin: Otherwise, skin warm, dry
Pertinent Results:
SEROLOGY:
___ 11:10AM BLOOD WBC-6.4 RBC-4.79 Hgb-14.4 Hct-42.1 MCV-88
MCH-30.1 MCHC-34.2 RDW-14.9 Plt ___
___ 11:10AM BLOOD Neuts-72.4* Lymphs-17.3* Monos-7.8
Eos-2.1 Baso-0.3
___ 11:10AM BLOOD Glucose-80 UreaN-14 Creat-0.9 Na-138
K-4.9 Cl-99 HCO3-26 AnGap-18
___ 11:27AM BLOOD Lactate-1.9
IMAGING:
___ RLE doppler FINDINGS:
There is normal compressibility, flow and augmentation of the
right common femoral, superficial femoral, and popliteal veins.
Normal color flow and compressibility are demonstrated in the
posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral
veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower
extremity veins.
Brief Hospital Course:
___ y/o M w/ HIV (CD4 >500, VL undetectable per ___ records
from ___, HCV presents with ___ erythema found to be bilateral
cellulitis which impaired his ability to walk. Patient was given
IV Vancomycin for 1 day and symptoms drastically improved. He
was transitioned to oral antibiotics with a prescription for
keflex and bactrim to complete a ___ellulitis--
Non-purulent. Affecting patient's mobility. Recieved single dose
of vancomycin in ED and continued Vancomycin 1 g q 12h
overnight. His erythema and tenderness vastly improved on
hospital day #2 and he was transitioned to a PO regimen of
keflex/bactrim to complete at 7 day course. He will follow-up
resolution of his symptoms at PCP visit scheduled for him.
#Opiate abuse--
Pt reports recent hospitalization at ___ for opiate
overdose. Reports last use 2 days prior to admission. Defers
further details at this time. Per ___ record has been on
Suboxone therapy in the past. Treated supportively with ___ as
needed with below precautions but patient showed no signs of
active withdrawal through hospital course. Patient reports on
list for suboxone therapy and will follow-up with PCP at
scheduled visit.
#HIV--Last CD4 725, VL 194 in our records on ___, though
patient reported CD4 count >500 with undetectable viral load on
___ which was confirmed with ___ progress notes. Pt reports
adherence to HIV regimen. Call to pharmacy reveals medication
prescriptions refilled ___. Continued home ART therapy per
home regimen.
#anxiety
Continued medications per home regimen.
-Clonazapam 0.5 mg PO TID PRN
-Paroxetine 40 mg PO daily.
TRANSITIONAL ISSUES
-Patient will continue antibiotics as prescribed up to and on
___. Asked patient to follow-up resolution of symptoms with
PCP at scheduled appointment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
2. Atazanavir 300 mg PO DAILY
3. RiTONAvir 100 mg PO DAILY
4. Paroxetine 40 mg PO DAILY
5. ClonazePAM 0.5 mg PO TID:PRN anxiety
6. DiphenhydrAMINE 50 mg PO QHS:PRN insomnia
Discharge Medications:
1. Atazanavir 300 mg PO DAILY
2. ClonazePAM 0.5 mg PO TID:PRN anxiety
3. DiphenhydrAMINE 50 mg PO QHS:PRN insomnia
4. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
5. Paroxetine 40 mg PO DAILY
6. RiTONAvir 100 mg PO DAILY
7. Cephalexin 500 mg PO Q6H
Please continue up to and on ___
RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*24 Capsule Refills:*0
8. Sulfameth/Trimethoprim DS 1 TAB PO BID
Please continue up to and on ___
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*12 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted with concern for your skin infection. You
recieved a strong IV antibiotic that would help you get rid of
this infection. Your symptoms improved dramatically on hospital
day #2 and you were transitioned to a prescribed oral course of
2 antibiotics. Please complete this course as prescribed in
order to give yourself the best chance of clearing the
infection. Please call a physican or return to the emergency
department if your symptoms worsen. Please follow-up with your
primary care provider ___ ___ weeks.
Wishing you the best of health,
Your ___ Team
Followup Instructions:
___
|
10142413-DS-8 | 10,142,413 | 24,004,865 | DS | 8 | 2153-09-07 00:00:00 | 2153-09-12 12:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Vicodin / lidocaine / Bactrim
Attending: ___.
Chief Complaint:
==================================
Hospital Medicine Admission Note
==================================
cc: abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ y/o female with history of Crohn's disease
currently in remission x ___ years who presented with one day of
severe RUQ/RLQ abdominal pain. She reports the pain started
yesterday after having brunch and has gradually gotten worse. It
is currently ___ in severity. She vomited at home, but did not
have associated nausea. She has not moved her bowels since
yesterday and is not passing gas, which is unusual for her. She
usually has bowel movements after eating, ___ x day. She has not
noticed blood in stool and was feeling fine before yesterday.
She reports that she has been off of all medications for Crohn's
for the last ___ years. Her gastroenterologist is Dr. ___ in
___, but has not seen him in at least a year, per Atrius
records. She had a colonoscopy ijn ___ which years ago which
was normal and an EGD in ___ which showed an esophageal
ulcer which resolved with PPI treatment.
She started IVF treatment in ___ and started her
second cycle 2, with embryo transfer on ___
Past Medical History:
PMH: Crohn's disease, off treatment x ___ years
Past surgical history:
___ appendectomy
___ Colectomy
___ Colostomy takedown
___ Laparotomy, right ovarian cystectomy
___ Lap cholecystectomy
___ L5/S1 discectomy
Social History:
___
Family History:
Father: diabetes, hypertension
Mother: ___
Physical ___:
VS: T: 99.8 Bp: 109/60 HR: 109 R: 18 O2: 96% RA
Young female laying in bed in some distress secondary to pain.
HEENT: MMM, NGT in place in right nare. No oral ulcers
Lungs: Clear B/L on auscultation
___: RRR, S1, S2 present, Tachycardic- no murmurs
Abdomen: Large midline abdominal scare. Soft. significant
tenderness on palpation of RLQ, RUQ, + rebound and referred pain
to RLQ on palpation of left.
Ext: No edema, clubbing or cyanosis, no rashes
Pertinent Results:
___ 12:10AM ___ PTT-28.3 ___
___ 12:10AM PLT COUNT-388
___ 12:10AM NEUTS-89.1* LYMPHS-7.1* MONOS-3.4 EOS-0.2
BASOS-0.2
___ 12:10AM WBC-18.3* RBC-4.39 HGB-13.2 HCT-39.6 MCV-90
MCH-30.0 MCHC-33.3 RDW-12.5
___ 12:10AM estGFR-Using this
___ 12:10AM GLUCOSE-107* UREA N-12 CREAT-0.5 SODIUM-142
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-21* ANION GAP-19
___ 12:52AM LACTATE-1.5
Imaging:
Pelvic ultrasound:
IMPRESSION:
1. 2.7 cm cyst within the right adnexa may represent a
hemorrhagic cyst. Follow-up ultrasound is recommended.
2. No evidence of torsion.
3. No intra-gestational sac is seen. The differential includes
early IUP with ectopic pregnancy not excluded on this exam.
Serial b-hCG and ultrasound is recommended.
4. Tubular right adnexal structure represents a bowel loops or
hydrosalpinx.
MRI abdomen/pelvis:
IMPRESSION:
1. Inflammatory changes and edema adjacent to a thickened loop
of ileum in the right mid to lower abdomen. Findings may be
secondary to adhesions or a component of a subacute Crohn's
flare. Further differentiation is difficult due to lack of IV
contrast and if there is change clinically, repeat exam can be
performed.
2. Isolated, dilated loop of distal ileum may be related to
postsurgical
anatomy. There is no definite evidence of upstream obstruction
as the
remainder of the small bowel is normal in caliber.
Brief Hospital Course:
This is a ___ y/o female with Crohn's disease, multiple abdominal
surgeries, currently undergoing IVF who presnents with severe,
acute abdominal pain.
Active Crohn's disease vs bowel obstruction
Patient had signficiant and acute pain. She also had elevated
WBC and low grade fever. MRI abdomen preliminary report showed
"Inflammatory changes and edema adjacent to a thickened loop of
ileum in the right mid to lower abdomen" which correlated with
the location of her pain. She was started on IV steroids and
then transitioned to PO prednisone upon improvement of symptoms.
She was on dilaudid intermittently for pain control although
this improved near discharge and was not requiring any dilaudid.
Infertility, currently undergoing IVF
Discussed with reproductive endocrinology fellow Dr. ___.
Patient is ___ days s/p embryo transfer and was considered
potentially pregnant. From a GYN perspective, patient was known
to have right hydrosalpinx. She did have a pregnancy test during
the admission which was negative; she will follow up with IVF as
outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Prenatal Vitamins 1 TAB PO DAILY
2. Crinone (proGESTerone micronized) 4 % vaginal Qday
Discharge Disposition:
Home
Discharge Diagnosis:
1. Crohn's disease flare
2. Invitro fertilization
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 worsening abdominal pain that we felt was
consistent with worsening of your Crohn's disease. To treat
you, we had you fast and started you on steroids. You had
improvement in your symptoms. You will need to stay on
prednisone as directed below until you see your primary care
physician and gastroenterologist. Your GI doctor ___ likely
recommend a colonoscopy for further evaluation at that time. You
also were being seen by Obstetrics for IVF. You had a
pregnancy test on ___ (day of discharge) which was
negative. Please continue to work with Obstretrics regarding
your IVF treatments.
Followup Instructions:
___
|
10142447-DS-5 | 10,142,447 | 26,010,176 | DS | 5 | 2168-09-17 00:00:00 | 2168-09-17 15:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o man with a PMH of CAD s/p CABGx3, T1DM c/b
prior DKA, glaucoma, hypertension, and chronic pain, who
presented to the ED with malaise, found to be hyperglycemic with
anion gap metabolic acidosis in DKA.
He presented to the ED today with hyperglycemia to the 500s and
"just not feeling right" in the last day. He denied fever, pain,
CP, SOB, or other specific symptoms, but his wife apparently
became concerned as the last time he complained of similar
nonspecifically feeling poorly it was a silent MI. Of note, he
was seen in the ___ ED earlier this week for leg edema, with a
BNP of ~500, and was prescribed a five-day course of Lasix, with
a plan for outpatient follow-up. At that time, he was found to
have blood sugars in the 400s, without an anion-gap acidosis,
but he refused insulin in the emergency room, saying that he
would take his own insulin.
In the ED, initial vitals: T 99.4F BP 117/60 mmHg P ___ RR 18 O2
100% RA
- Exam within normal limits
- Labs were notable for Na 131, K 5.4, Cl 91, HCO3 17, BUN 22,
Cr 1.2, Gluc 600. Ca 9.7, Mg 2.2, P 5.2. Trop-T < 0.01, MB 2.
CBC w/ WBC 7.6, H/H 12.0/37.0, PLT 320. VBG: 7.3/___.
- Imaging showed no acute cardiopulmonary process.
- Patient was given: 1L NS, insulin gtt started
- Consults: ___
On arrival to the MICU, he noted that he felt like "the acidosis
again," but was not able to describe any specific symptoms. He
denied fevers, chills, cough, sick contacts, chest pain,
shortness of breath, nausea, vomiting, diarrhea, melena, or
hematochezia. He did endorse dysuria, without hematuria. He may
have missed his dose of Lantus yesterday, although he is not
clear.
ROS
- as above, otherwise a 10 point review of systems was negative
Past Medical History:
PMH
- T1DM w/ neuropathy and DKA
- history of alcohol and drug abuse
- history of tobacco use
- tendinitis
- ?CHF
- ED
- HLD
- bone spurs
PSH
- CAD s/p CABGx3
- cataract surgery
Social History:
___
Family History:
- brother died of colon cancer
- no history of diabetes or heart disease in the family
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
VS: T 98.2F BP 125/58 mmHg P 72 RR 16 O2 99% RA
General: Thin man, irritable, in NAD.
HEENT: Poor dentition. MMM. R eye cataract. Left pupil round and
reactive.
Neck: Supple, no JVD. No LAD.
CV: Midline thoracic scar. RRR, loud S1, III/VI systolic murmur.
Pulm: Mild crackles at base, L>R.
Abd: Soft, non-tender, non-distended. NABS
Ext: Warm and well-perfused. No edema. 2+ pulses.
Neuro: A&Ox3. CNs II-XII grossly intact. Distal sensation intact
to light touch.
=======================
DISCHARGE PHYSICAL EXAM
=======================
VS: T: 97.8 HR: 80 BP: 115/71 RR: 20 100% RA
Gen: NAD, resting comfortably in bed
HEENT: EOMI, MMM, right eye cataract, left pupil reactive
CV: RRR nl s1s2 no m/r/g, no JVD, well healed incision
Resp: CTAB no w/r/r
Abd: Soft, NT, ND +BS
Ext: no c/c/e
Neuro: CN II-XII intact, ___ strength throughout
Psych: normal affect
Skin: warm, dry no rashes
Pertinent Results:
==============
ADMISSION LABS
==============
___ 10:13AM BLOOD WBC-7.6 RBC-3.93* Hgb-12.0* Hct-37.0*
MCV-94 MCH-30.5 MCHC-32.4 RDW-15.9* RDWSD-55.5* Plt ___
___ 10:13AM BLOOD Neuts-80.8* Lymphs-11.3* Monos-4.9*
Eos-0.8* Baso-0.9 Im ___ AbsNeut-6.14* AbsLymp-0.86*
AbsMono-0.37 AbsEos-0.06 AbsBaso-0.07
___ 10:13AM BLOOD Glucose-600* UreaN-22* Creat-1.2 Na-131*
K-5.4* Cl-91* HCO3-17* AnGap-28*
___ 10:13AM BLOOD CK(CPK)-32*
___ 10:13AM BLOOD cTropnT-<0.01
___ 10:13AM BLOOD CK-MB-2
___ 10:13AM BLOOD Calcium-9.7 Phos-5.2*# Mg-2.2 Iron-PND
___ 10:43AM BLOOD ___ pO2-41* pCO2-37 pH-7.30*
calTCO2-19* Base XS--7 Intubat-NOT INTUBA
___ 01:02PM BLOOD Glucose-GREATER TH Na-130* K-5.2* Cl-98
calHCO3-13
============
INTERIM LABS
============
___ 11:00PM BLOOD Glucose-93 UreaN-16 Creat-0.9 Na-134
K-3.7 Cl-100 HCO3-26 AnGap-12
___ 10:13AM BLOOD %HbA1c-11.3* eAG-278*
___ 10:13AM BLOOD calTIBC-296 Ferritn-162 TRF-228
==============
DISCHARGE LABS
==============
===============
IMAGING/STUDIES
===============
CHEST (PA & LAT) (___):
FINDINGS:
Midline sternotomy wires are present with fracture through the
most superior sternotomy wire, new since ___. Multiple
surgical clips overlie the mediastinum. The lungs are clear
without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes
are unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
TTE ___:
The left atrium is elongated. 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>60%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Mild biatrial enlargement. Normal biventricular
chamber size and systolic function. No pathologic valvular flow.
Minimally dilated ascending aorta.
___:10AM BLOOD WBC-4.9 RBC-3.37* Hgb-10.4* Hct-30.8*
MCV-91 MCH-30.9 MCHC-33.8 RDW-15.4 RDWSD-51.1* Plt ___
___ 07:08AM BLOOD Glucose-237* UreaN-20 Creat-0.8 Na-136
K-4.4 Cl-98 HCO3-28 AnGap-11
___ 07:10AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.2
Brief Hospital Course:
Mr. ___ is a ___ y/o man with a PMH of CAD s/p CABGx3, T1DM c/b
prior DKA, glaucoma, hypertension, and chronic pain, who
presented to the ED with malaise, found to be hyperglycemic with
anion gap metabolic acidosis in DKA.
# T1DM WITH DKA. Presented with blood glucose of 600. Endorsed
dysuria, but not polyuria or polydipsia. Trigger appears to have
been missing dose of insulin glargine ___. Infectious work-up
was negative, with no leukocytosis and no consolidation on CXR.
UA and urine culture were similarly negative. He was placed on
an insulin gtt and kept NPO with ___ consult, hourly blood
glucose checks and q6h chemistries with aggressive K, Mg, and
phosphate repletions. He was started on ___ NS as his blood
sugars fell below 250, with anion gap closed at ___. He was
started on a diet, home Lantus increased to 8 units and placed
on standing lispro with meals and more aggressive sliding scale.
His blood sugars were under significantly better control in
high 100s to low 200s.
-Continue Lantus 8 units qHs, standing lispro with meals, lispro
sliding scale and additional 1 unit per 12 grams of carbs
correction factor.
# Normocytic anemia. Hemoglobin stable at 10.4 on discharge, no
signs of bleeding or hemolysis.
-Consider outpatient anemia work-up including endoscopy as
indicated.
# Possible chronic dCHF. Presented several days prior to
admission to ___ ED with edema and was prescribed Lasix 20 mg
daily. On admission here he was volume depleted from DKA.
Lasix was held, TTE showed no significant abnormalities. Lasix
was held on discharge, counseled patient to monitor for swelling
and discuss with PCP restarting ___ as needed.
==============
CHRONIC ISSUES
==============
# Cataracts. Continued home atropine/prednisolone drops.
# CAD. s/p CABG. Continued home atorvastatin 10 mg and
metoprolol succinate 50 mg daily.
# HTN. Continue lisinopril 2.5 mg daily.
#Medical adherence: He reports being extremely fed up with the
medical system and with the expense of everything. He has
stopped following up with most of his specialists and has been
taking very poor care of his medical problems. Discussed at
length with patient and his wife that if he does not take better
control of his medical issues quickly he will suffer worsening
complications and possibly death. His wife appears to
understand this and he now is agreeing to outpatient ___
follow-up.
-Encourage outpatient follow-up as above.
# CONTACT: ___, ___
# Code: FULL
Dispo: home with services
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Furosemide 20 mg PO DAILY
2. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
3. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES BID
4. ofloxacin 0.3 % ophthalmic DAILY
5. Atropine Sulfate Ophth 1% 1 DROP BOTH EYES QID
6. Glargine 6 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Lisinopril 2.5 mg PO DAILY
8. Atorvastatin 10 mg PO QPM
9. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. Atorvastatin 10 mg PO QPM
2. Atropine Sulfate Ophth 1% 1 DROP BOTH EYES QID
3. Glargine 8 Units Bedtime
Humalog 4 Units Breakfast
Humalog 4 Units Lunch
Humalog 4 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin lispro [Humalog KwikPen] 200 unit/mL (3 mL) AS DIR
units SC Before meals and before bedtime Disp #*2 Syringe
Refills:*0
4. Lisinopril 2.5 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
7. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES BID
8. Aspirin 81 mg PO DAILY
9. ofloxacin 0.3 % OPHTHALMIC DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
DKA
Poorly controlled DM I
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for recurrent diabetic ketoacidosis (DKA).
You were initially in the intensive care unit and required an
insulin drip. The ___ diabetes team saw you here. Your
blood sugars improved and your home insulin regimen was
increased. Take the sliding scale as prescribed in addition to
taking 1 unit of Humalog for every 12 grams of carbohydrates in
your meals. Please follow-up with your primary care physician
and ___ as scheduled. You were recently started on Lasix, we
recommend stopping this and discussing with your PCP if you
develop leg swelling again.
Followup Instructions:
___
|
10142844-DS-22 | 10,142,844 | 25,227,088 | DS | 22 | 2177-08-22 00:00:00 | 2177-08-22 22:10:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ presented to the emergency department with lower abdominal,
epigastric and left flank pain associated with nausea and
vomiting ___ times per day over ___ last 3 days. He denies any
fevers. He does endorse dysuria x1. Denies any shortness of
breath. No diarrhea
In the ED intial vitals were: 96.8 138 170/96 18 94% RA.
- Labs were significant for lipase 61, WBC 14.7 (82%PMN), Cr
1.1, K 4, Trop-T: <0.01 x1, ALT 44, AST 21. CT abd-pelvis
without contrast showed per prelim read fat stranding
surrounding the tail of the pancreas and thickening of the
adjacent peritoneum is concerning for focal pancreatitis. Patent
splenic artery and vein. No free fluid or fluid collection. No
renal stones, pyelonephritis or diverticulitis. CXR PA and LAT
showed low lung volumes and bibasilar atelectasis. Patient was
given IV zofran 4 mg x1, IV morphine 5 mg x1, ASA 325 mg x1. Pt
is being admitted for fluid resuscitation and pain control.
Vitals prior to transfer were: 99.3 107 148/82 22.
On the floor, pt complains of abdominal pain that is ___.
Review of Systems:
(+) per HPI
Past Medical History:
- Depression
- Migraine
- Syncope ___ attributed to History of orthostasis coupled with
alcohol consumption (at that time, ETOH level of 269)
- bifrontal SDHs in ___
- h/o alcoholism
- s/p repair of orbital floor fractures
- s/p fractures left ulna with pinning
- right talus fracture ___
Social History:
___
Family History:
Has had 5 family members die at young age (___) of "heart
attacks" or "heart failure". Brother with bipolar depression.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - 98.8 114/98 112 20 98RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, nontender supple neck, no LAD, no JVD
CARDIAC: Regular rhythm, slightly tachycardic, N S1/S2, no
murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, non tender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII grossly intact
DISCHARGE PHYSICAL EXAM:
Vitals: 99.6 (99.6) 128/68 95 16 95% RA
Tele: SR 90-110, < 100 since 2300 last night
GENERAL: alert and oriented, NAD
HEENT: AT/NC, EOMI, MMM, OP clear
CARDIAC: RRR, Nl S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, non tender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema.
Pertinent Results:
ADMISSION LABS:
___ 06:40PM BLOOD WBC-14.7*# RBC-4.92 Hgb-16.4 Hct-45.9
MCV-93 MCH-33.3* MCHC-35.7* RDW-13.0 Plt ___
___ 06:40PM BLOOD Neuts-82.4* Lymphs-11.9* Monos-4.5
Eos-0.9 Baso-0.2
___ 06:40PM BLOOD Glucose-138* UreaN-16 Creat-1.1 Na-136
K-4.0 Cl-100 HCO3-21* AnGap-19
___ 06:40PM BLOOD ALT-44* AST-21 AlkPhos-91 TotBili-1.2
___ 06:40PM BLOOD Lipase-61*
___ 06:40PM BLOOD cTropnT-<0.01
___ 11:00PM URINE Color-Straw Appear-Clear Sp ___
___ 11:00PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 11:00PM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
DISCHARGE LABS:
___ 06:45AM BLOOD WBC-9.5 RBC-4.23* Hgb-14.1 Hct-40.6
MCV-96 MCH-33.3* MCHC-34.6 RDW-13.0 Plt ___
___ 06:45AM BLOOD Glucose-90 UreaN-6 Creat-0.9 Na-136 K-4.0
Cl-101 HCO3-27 AnGap-12
___ 06:45AM BLOOD Calcium-8.6 Phos-2.1* Mg-2.2
MICROBIOLOGY: NONE
IMAGING:
CT ABDOMEN/PELVIS ___:
FINDINGS: Linear opacity at the lung bases most likely
represents atelectasis or scarring. A nodule in the right lung
base measures 2 mm. There is no pleural or pericardial
effusion. Diffuse hypodensity of the liver parenchyma indicates
hepatic steatosis. There are no focal liver lesions. The
gallbladder appears normal. Fat stranding adjacent to the tail
of the pancreas may represent focal pancreatitis. The left
renal fascia is thickening and there is adjacent fat stranding.
The spleen and adrenal glands appear normal. The kidneys
enhance symmetrically
and promptly excrete contrast. No renal stones or concerning
renal lesions are identified. The bladder is partially filled
and appears normal. The prostate is unremarkable. The stomach
is decompressed. The small bowel appears normal without
evidence of wall thickening or obstruction. There is colonic
diverticulosis without evidence of diverticulitis. The appendix
is visualized in the right lower quadrant and appears normal.
There is no free fluid, free air or pathologic lymphadenopathy
by CT size criteria. There are calcifications within a normal
caliber aorta.
OSSEOUS STRUCTURES: No concerning osteoblastic or osteolytic
lesions identified.
IMPRESSION:
1. Fat stranding adjacent to the tail of the pancreas and
thickening of the left pararenal fascia is most consistent with
acute pancreatitis. There is no decreased pancreatic
parenchymal enhancement, peripancreatic free fluid or fluid
collections. No biliary dilation or gallstones identified.
2. The kidneys appear normal without evidence of stones,
hydronephrosis or masses.
3. Hepatic steatosis.
4. Diverticulosis without evidence of diverticulosis.
5. A nodule in the right lung base measures 2 mm. Follow-up CT
in ___ year is recommended if the patient has risk factors for
lung cancer or known prior malignancy.
RUQ U/S ___:
FINDINGS: The liver is mildly echogenic, consistent with fatty
deposition. No focal lesions or intrahepatic biliary ductal
dilatation is seen. The common bile duct is normal measuring
0.4 cm. The pancreas is not assessed on this exam. The
gallbladder is normal without evidence of cholelithiasis or
cholecystitis. Doppler assessment of the main portal vein
demonstrates normal hepatopetal flow. There is no evidence of
ascites. Limited assessment of the right kidney is unremarkable.
IMPRESSION:
1. No evidence of cholelithiasis or cholecystitis.
2. Echogenic liver is consistent with fatty deposition. More
advanced forms of liver disease such as cirrhosis or hepatic
fibrosis cannot be excluded by this study, however.
CXR ___:
FINDINGS: The lung volumes are low. There is persistent mild
relative elevation of the right hemidiaphragm compared to the
left side. The cardiac, mediastinal and hilar contours appear
stable. There is no pleural effusion or pneumothorax. New
streaky opacities involve each lung base as well as the left mid
lung, the latter probably associated with the lingula. This
appearance is very suggestive of minor atelectasis. Elsewhere,
the lungs appear clear.
IMPRESSION: New basilar opacities, most likely due to
atelectasis.
Brief Hospital Course:
___ with PMH of migraine, depression and history of alcoholism
is admitted with abdominal pain, nausea and vomiting and CT
findings strongly suggestive of pancreatitis.
# Abdominal pain: Patient presented with 2 days of N/V/abdominal
pain. CT findings suggestive of pancreatitis with lipase of 61.
RUQ u/s and CT do not suggest cholestatic source, and ALP was
normal. Leukocytosis on admission was probably reactive to
pancreatitis, resolved. No fever during admission. Abdominal
exam benign. Patient felt better by the morning after
admission, without emesis for almost 48 hours and with improved
appetite, able to tolerate solid foods. Provided IV morphine
and then PO oxycodone for pain control. Used IV ativan for
nausea control given QTc prolongation.
# Sinus tachycardia: Initially was in sinus tachycardia 100-120s
on admission. No known history of tachycardia. ___ be
associated with dehydration and pain, no other clear sympathetic
drivers. Resolved with IVF.
# Long QT: No obvious QT prolonging medications. Avoided
Zofran, compazine given this EKG finding. No evidence of
arrhythmia on telemetry.
# Hip pain: Likely MSK given resolution with passive ROM.
Resolved by discharge.
# Depression: continued Wellbutrin
# Migraine: held home Fioricet
# Code: full - confirmed with pt
# Emergency Contact: ___ (friend) ___
TRANSITIONAL ISSUES:
- CT abdomen: there was a 2 mm right lower lobe nodule.
Follow-up CT in ___ year is recommended if the patient has risk
factors for lung cancer. No follow-up is recommended if the
patient does not have any risk factors.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen-Caff-Butalbital 1 TAB PO BID:PRN migraine
2. Wellbutrin XL (buPROPion HCl) 300 mg oral daily
Discharge Medications:
1. Acetaminophen-Caff-Butalbital 1 TAB PO BID:PRN migraine
2. Wellbutrin XL (buPROPion HCl) 300 mg oral daily
3. Lorazepam 0.5 mg PO Q4H:PRN nausea
___ cause sedation. Do not drive while using.
RX *lorazepam 0.5 mg 1 tablet by mouth every eighter hours Disp
#*10 Tablet Refills:*0
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
___ cause sedation. Do not drive while using. ___ cause
constipation.
RX *oxycodone 5 mg 1 tablet(s) by mouth every six hours Disp
#*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
pancreatitis
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 at ___
___. You came to the hospital with abdominal pain
and nausea. You were also found to be dehydrated. A CT scan
showed inflammation of your pancreas. You were treated with IV
fluids, pain medication, and bowel rest. You then advanced your
diet and were able to tolerate some solid foods before
discharge. We recommend that you avoid fatty or spicy foods for
the next few days as you recover. Be sure to drink plenty of
fluids; your urine should be light yellow to indicate you are
hydrated.
We have given you a prescription for pain medication for the
next week. If you find that you have pain that requires more
medication, please contact your primary care physician Dr ___.
You have an appointment scheduled with Dr ___ ___.
Followup Instructions:
___
|
10142844-DS-23 | 10,142,844 | 22,340,248 | DS | 23 | 2181-01-06 00:00:00 | 2181-01-07 19:46:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
syncope, respiratory failure
Major Surgical or Invasive Procedure:
Intubation ___
Extubation ___
History of Present Illness:
___ with history of cluster headaches, anxiety, EtOH use
disorder, depression and syncopal episode in ___ who was
brought to ___ ED by EMS after a witnessed syncopal episode
with headstrike, with progressive AMS and hypoxia requiring
intubation in the ED, admitted to ICU for syncope and hypoxia
workup.
On the day prior to admission ___ he was sitting on a bench and
was witnessed by friends to fall, landing on his face, without
appreciable seizure-like activities or shaking afterwards. This
was in the setting of drinking 5 beers. He was somewhat
confused after the event and there is a report of 5 minute LOC
and ENS bag-mask ventilation. He was afebrile, tachycardic to
120, BP 160/96 in the field with FSG 135. He was transferred to
___ ED.
In ED initial VS: 97.1 | 120 | 134/88 | 18 | 95% RA
He was alert and oriented x3 but was perseverating. he denied
any chest pain, shortness of breath, abdominal pain, cough,
fever, chills, nausea or vomiting. Denies any other illness
prior to this episode. No history of seizures though has had
syncope in ___ with facial fracture, and has had head trauma
d/t falls and assault in the past.
Exam: His exam was notable to A&Ox4, NAD but pale and
diaphoretic. Abrasions were noted over right supraorbital
region. No other signs of external trauma. He was moving all
extremities.
Given initial normal labs and imaging, including CTA chest and
CXR, he was enrolled into the syncope pathway and was to be in
ED-obs overnight for echocardiogram in AM to complete syncope
workup.
In the ED he was noted to have some transient episodes of
hypoxia to 80-85% on RA which initially improved with ___ NC.
At 0230, he was noted to have progressive worsening hypoxia,
"then sudden change in mental status and apnea requiring
intubation," with fent/versed for sedation. At the time he
seemed to have some right gaze deviation, LLE twitching and
right hand clenching.
Labs significant for:
- initial WBC 10.5 | H/H 16.0/46.5 | 277
- Na 142 | K 4.8 | Cl 102 | Bicarb 22 | BUN 13 | Cr 1.3 | Glu
136
- proBNP 8
- ALT 20 | AST 19 | AP 72 | Lip 58 | Tbil 0.2 | Alb 4.9
- EtOH serum 102, APAP/benzo/barb/tricyc neg
Patient was given: 1L NS initially, then for sedation 2mg
lorazepam, IV gtt midazolam/fentanyl.
Imaging notable for:
___ CXR: FINDINGS: AP upright and lateral views of the chest
provided. Mild left basal atelectasis is noted. There is no
focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous
structures are intact. No free air below the right
hemidiaphragm is seen.
IMPRESSION: No acute intrathoracic process.
___ CT-PE IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Mild bronchial wall thickening suggestive of airway
inflammation.
___ CT HEAD IMPRESSION: No acute intracranial process.
Consults: Neurology was consulted for possible seizure and
recommended admission to MICU, r/o cardiac and metabolic cause,
and cvEEG.
VS prior to transfer: 89 | 104/70 | 16 | 99% intubated.
On arrival to the MICU, he was intubated and minimally able to
respond to questions though he seemed to deny any similar
events, and any current pain or nausea.
REVIEW OF SYSTEMS: Pt intubated, sedated, unable to provide
Past Medical History:
- Depression
- Migraine
- Syncope ___ attributed to History of orthostasis coupled with
alcohol consumption (at that time, ETOH level of 269)
- bifrontal SDHs in ___
- h/o alcoholism
- s/p repair of orbital floor fractures
- s/p fractures left ulna with pinning
- right talus fracture ___
Social History:
___
Family History:
- heart disease
- father: CAD in ___ (smoker)
- mother: smoker, died in a fire at ___, ?MI
- brother: CAD early ___ (drinking, smoking); bipolar
depression
- ___: MI in ___
- no DM
- no cancer
Has had 5 family members die at young age (___) of "heart
attacks" or "heart failure".
Physical Exam:
ADMISSION LABS
==============
VITALS: 89 | 104/70 | 16 | 99% RA
GENERAL: Intubated, rouses easily to voice, tracks, follows
commands, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated
LUNGS: Clear to auscultation bilaterally on lateral fields w/o
wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No mottling. 1-2cm abrasion above right orbit and on left
knee.
NEURO: intubated, RAS -1, follows ___ step commands. Pupils
equal and reactive, EOMI, strength ___ dorsal/plantarflexion but
possible 3+ left thigh extension (vs. poor
attention/participation). Reflexes symmetric and not appreciably
abnormal, possible 1 beat clonus.
DISCHARGE EXAM
==============
VS: Tmax 100.1 Tc 99 86 137/75 23 96% 3L NC
I/Os: +2869 24H, LOS +3L
Awake, alert, NAD
RRR no MRG
CTAB, NLB on RA
Abd soft, NT
A&O, SILT, MAE
WWP, no edema
Pertinent Results:
ADMISSION LABS
===============
___ 08:07PM BLOOD WBC-10.5* RBC-4.94 Hgb-16.0 Hct-46.5
MCV-94 MCH-32.4* MCHC-34.4 RDW-13.3 RDWSD-45.7 Plt ___
___ 08:07PM BLOOD Neuts-65.7 ___ Monos-8.7 Eos-0.5*
Baso-0.7 Im ___ AbsNeut-6.89* AbsLymp-2.48 AbsMono-0.91*
AbsEos-0.05 AbsBaso-0.07
___ 08:07PM BLOOD ___ PTT-29.2 ___
___ 08:07PM BLOOD Glucose-136* UreaN-13 Creat-1.3* Na-142
K-4.8 Cl-102 HCO3-22 AnGap-18*
___ 08:07PM BLOOD ALT-20 AST-19 AlkPhos-72 TotBili-0.2
___ 08:07PM BLOOD Albumin-4.9 Calcium-9.4 Phos-6.6* Mg-2.2
___ 08:07PM BLOOD ___ Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
INTERVAL & DISCHARGE LABS
==========================
___ 02:28AM BLOOD Type-ART FiO2-100 pO2-328* pCO2-58*
pH-7.22* calTCO2-25 Base XS--4 AADO2-329 REQ O2-60
Intubat-INTUBATED Vent-CONTROLLED
___ 04:10AM BLOOD WBC-10.6* RBC-4.05* Hgb-13.0* Hct-38.2*
MCV-94 MCH-32.1* MCHC-34.0 RDW-13.2 RDWSD-45.8 Plt ___
___ 04:10AM BLOOD Glucose-108* UreaN-10 Creat-0.8 Na-137
K-3.9 Cl-98 HCO3-26 AnGap-13
___ 08:07PM BLOOD cTropnT-<0.01 proBNP-8
___ 01:46AM BLOOD cTropnT-<0.01
STUDIES
=======
___ CXR IMPRESSION: No acute intrathoracic process.
___ CTA CHEST IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Mild bronchial wall thickening suggestive of airway
inflammation.
___ CT HEAD w/o CONTRAST IMPRESSION: No acute intracranial
process.
___ ECHOCARDIOGRAM Conclusions: The left atrium is normal in
size. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Left ventricular systolic function is hyperdynamic (EF
= 75%). The right ventricular free wall thickness is normal.
Right ventricular chamber size is normal with borderline normal
free wall function. The aortic root is mildly dilated at the
sinus level. The aortic arch is mildly dilated. The number of
aortic valve leaflets cannot be determined. There is no aortic
valve stenosis. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is systolic anterior
motion of the mitral valve leaflets. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
the left ventricle is now hyperdynamic with mitral valvular (and
chordal) systolic anterior motion but no manifest resting left
ventricular outflow tract obstruction.
Brief Hospital Course:
___ with history of migraines/cluster HA, anxiety, EtOH use
disorder, depression and syncopal episode in ___ who was
brought to ___ ED by EMS after a witnessed syncopal episode
with headstrike, with progressive AMS and hypoxia requiring
intubation in the ED, admitted to ICU for syncope and hypoxia
workup, no evidence of arrhythmia, LV dysfunction, valvular
disease, further seizure activity on EEG. Patient was loaded
with phenobarbital and extubated. He chose to leave against
medical advice and demonstrated capacity to make this decision.
#POSSIBLE SEIZURES
#EtOH USE DISORDER
Witnessed syncope in the setting of drinking, with no obvious
seizure activity until possible clenching/gaze deviation the ED.
No known history of withdrawal seizures. Blood tox screen
negative except for EtOH; Utox only with benzo. Neg PE, neg trop
x2, neg CT head, TTE without obvious abnormality. Does have
history of head trauma more likely. Has syncopized in ___ (also
in setting of drinking)for which he was admitted to cardiology
here with negative extensive workup for malignant arrhythmia,
coronary pathology, or other etiology. On buproprion and
paroxetine can lower seizure threshold. CIWA 4. Phenobarb loaded
___. Patient left AMA ___. PCP was contacted and warm hand off
accomplished. Patient advised not to drink alcohol, take
bupropion or Fioricet or clonazepam given interactions with
phenobarbital.
#SYNCOPE
No evidence of arrhythmia, LV dysfunction or valvular disease.
Possibly due to withdrawal seizures. Orthostatic vital signs
were planned but patient left AMA.
#COFFEE GROUND EMESIS:
Coffee grounds coming up with OG, resolved with PPI, H/H stable,
tolerated regular diet after extubation. Discharged with script
for omeprazole 20mg QD.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. BuPROPion XL (Once Daily) 150 mg PO DAILY
2. PARoxetine 50 mg PO DAILY
3. ClonazePAM 1 mg PO BID
4. Fiorinal-Codeine #3 (codeine-butalbital-ASA-caff)
___ mg oral BID:PRN
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth Daily Disp #*30
Capsule Refills:*0
2. PARoxetine 50 mg PO DAILY
3. HELD- ClonazePAM 1 mg PO BID This medication was held. Do
not restart ClonazePAM until you discuss with you PCP
4. HELD- Fiorinal-Codeine #3 (codeine-butalbital-ASA-caff)
___ mg oral BID:PRN This medication was held. Do not
restart Fiorinal-Codeine #3 until you discuss with you PCP
___:
Home
Discharge Diagnosis:
#ALCOHOL USE DISORDER
#POSSIBLE WITHDRAWAL SEIZURE
#SYNCOPE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were brought to the ___ after a fall
and you had an episode that was though to be a seizure in the
ED. You needed a breathing tube and were admitted to the
Intensive Care Unit for monitoring after this episode. You were
given a very long lasting medication to protect yourself against
features (phenobarbital).
Fortunately, you were able to come off the breathing machine and
had no further episodes.
Unfortunately, you chose to left the hospital against medical
advice.
You understood the risks of leaving and especially of drinking
alcohol while the medication (phenobarbital) is active in your
body which include:
- Death from not breathing
- Low blood pressure
- Coma
We urge you NOT TO DRINK ALCOHOL as this may be life threatening
while the medication (phenobarbital) is in your system
We urge you to MAKE AN APPOINTMENT WITH YOUR PRIMARY CARE
DOCTOR.
___ do not take BUPROPION (WELLBUTRIN) or FIORICET or
CLONAZEPAM as these have interactions with the phenobarbital
that stays in your system for days.
Please talk your doctor about restarting these medications
We wish you the best in health,
Your ___ Team
Followup Instructions:
___
|
10143711-DS-7 | 10,143,711 | 27,783,888 | DS | 7 | 2161-02-14 00:00:00 | 2161-02-14 11:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Nafcillin / Penicillins / promethazine / codeine
Attending: ___.
Chief Complaint:
Right leg pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ dementia, end stage CHF on hospice, COPD on home oxygen
who presents from OSH s/p mechanical slip/fall last night.
Patient was splinted at the OSH and sent for further evaluation.
Pt endorses ongoing leg pain but denies numbness, tingling or
weakness. Denies other symptoms at this time.
Past Medical History:
ADENOCARCINOMA OF PROSTATE
ECZEMA
EMPHYSEMA
HYPERCHOLESTEROLEMIA
HYPERTENSION
ORBIT FRACTURE
OSTEOARTHRITIS
PULMONARY HYPERTENSION
CORONARY ARTERY DISEASE
ABDOMINAL AORTIC ANEURYSM
H/O BELL'S PALSY
H/O FRACTURED BONE
H/O OSTEOMYELITIS
H/O PNEUMONIA
H/O SMALL BOWEL OBSTRUCTION
H/O TOBACCO ABUSE
ORIF ELBOW ___
SMALL BOWEL RESECTION ___
HERNIA REPAIR
THYROGLOSSAL CYST RESECTION
Social History:
___
Family History:
Non-contributory.
Physical Exam:
AFVSS. NAD. On o2 NC.
Intermittent confusion.
- cast in place, skin intact
- No significant deformity, erythema, edema, induration or
ecchymosis
- Soft, non-tender thigh and leg
- Pain with movement of right leg
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Pertinent Results:
___ 03:45PM ___ PTT-31.1 ___
___ 03:45PM PLT COUNT-159
___ 03:45PM NEUTS-76.0* LYMPHS-11.0* MONOS-9.9 EOS-2.1
BASOS-0.6 IM ___ AbsNeut-5.38 AbsLymp-0.78* AbsMono-0.70
AbsEos-0.15 AbsBaso-0.04
___ 03:45PM WBC-7.1# RBC-4.20* HGB-12.8* HCT-42.5
MCV-101* MCH-30.5 MCHC-30.1* RDW-16.7* RDWSD-61.4*
___ 03:45PM CALCIUM-8.8 PHOSPHATE-3.0 MAGNESIUM-1.8
___ 03:45PM estGFR-Using this
___ 03:45PM GLUCOSE-98 UREA N-19 CREAT-0.7 SODIUM-145
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-29 ANION GAP-14
Brief Hospital Course:
Patient presented to the ___ ED with a right tibia/fibula
fracture. It was determined that given his hospice status, that
this would be treated non-operatively. He was placed in a cast
on ___ and remains non-weight bearing in the right lower
extremity. Medicine was consulted for assistance in care. Home
medications were continued during his stay. Anticoagulation was
deferred due to hospice status. He will return to his
rehab/hospice center on ___ with Rx for geriatric dosing of
oxycodone and stool softener. He will follow up for repeat
imaging in ___ weeks.
Medications on Admission:
Donepezil 5 mg PO/NG QHS
Memantine 10 mg PO DAILY
TraZODone 25 mg PO/NG QHS
Fluticasone Propionate 110mcg 2 PUFF IH BID
Furosemide 40 mg PO/NG DAILY
Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN wheezing
Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Donepezil 10 mg PO QHS
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Furosemide 40 mg PO DAILY
5. Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN wheezing
6. Memantine 10 mg PO BID
7. Metoprolol Succinate XL 25 mg PO DAILY
8. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Every ___ hours
Disp #*40 Tablet Refills:*0
9. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Closed R tibia/fibula fractures
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
-Please return to the emergency department or notify MD if you
experience severe pain, increased swelling, decreased sensation,
difficulty with movement; fevers >101.5, chills, redness or
drainage at the incision site; chest pain, shortness of breath
or any other concerns.
****CAST****
You have a fracture in your leg. This is being treated without
surgery. You have a cast on your leg. Do not get this wet. Keep
it clean and dry.
******MEDICATIONS***********
-PAIN MEDICATION: oxycodone, tylenol
-Do not operate heavy machinery or drink alcohol while taking
pain meds. As your pain improves please decrease the amount of
oxycodone. This medication can cause constipation, so you should
drink ___ glasses of water daily and take a stool softener
(colace) to prevent this side effect.
-Resume your pre-hospital medications with adjustments as noted
on discharge medication list.
Physical Therapy:
NWB RLE in cast
Treatments Frequency:
Cast to right leg - please keep clean and dry
To stay on until follow up
Followup Instructions:
___
|
10143896-DS-19 | 10,143,896 | 20,308,860 | DS | 19 | 2134-07-25 00:00:00 | 2134-07-31 04:17:00 |
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 breast pain
Major Surgical or Invasive Procedure:
breast I&D
History of Present Illness:
___ yo ___ presents to the ED with worsening left breast
pain in the setting of being treated for mastitis. Had been
taking dicloxacillin from ___ until ___. However, upon
follow-up at ___ reports it was not improving so her
antibiotics were switched. She had not filled the prescription
yet and did not know what antibiotic it was. She denies fever or
chills but has significant left breast pain. She did not take
anything for the pain. She stopped breast feeding on ___ due
to
pain.
Past Medical History:
POB/GYNH:
- G3P2102, SVDx3- two full term, one 32 week IUFD
- Hx of chlamydia in past
- H/o LSIL pap in past
PMH: Denies
Psurgh: Denies
Meds: tylenol, motrin
All: NKDA
SH: ___
Family History:
NC
Physical Exam:
On admission
Temp: 99 HR: 60 BP: 126/73 Resp: 18O2 Sat: 99
Gen: NAD
CV: RRR
Pulm: CTAB
Breast: diffuse edema and erythema of left breast between 10 and
3 o'clock. Extremely tender and warm on palpation. No discrete
area of abscess.
Abd: soft, nontender
Ext: nontender
Labs:
12.2>10.1/34.8<339
N:77.6 L:14.9 M:5.0 E:2.1 Bas:0.5
140 104 4
----------- < 85
3.9 25 0.5
On day of discharge
Left breast, erythema and induration have greatly improved.
Dressing is clean/dry/intact. Bed of wound is clean with pink
granulation tissue
Pertinent Results:
___:00AM BLOOD WBC-9.0 RBC-3.76* Hgb-9.0* Hct-30.3*
MCV-81* MCH-23.9* MCHC-29.6* RDW-14.7 Plt ___
___ 07:15AM BLOOD WBC-10.2 RBC-4.00* Hgb-9.5* Hct-32.6*
MCV-81* MCH-23.6* MCHC-29.0* RDW-14.8 Plt ___
___ 09:50PM BLOOD WBC-12.2* RBC-4.30 Hgb-10.1* Hct-34.8*
MCV-81* MCH-23.6* MCHC-29.2* RDW-14.6 Plt ___
___ 07:00AM BLOOD Neuts-75.2* Lymphs-16.5* Monos-5.5
Eos-2.6 Baso-0.2
___ 07:15AM BLOOD Neuts-75.6* Lymphs-15.4* Monos-5.3
Eos-2.7 Baso-1.0
___ 09:50PM BLOOD Neuts-77.6* Lymphs-14.9* Monos-5.0
Eos-2.1 Baso-0.5
Brief Hospital Course:
Ms. ___ was admitted for treatment of mastitis with
underlying breast abscess. She underwent an ultrasound guided
drainage and spontaneous drainage on ___ which largely
decompressed the abcess. On the morning of ___ the collection
had greatly increased and the breast surgery service was
consulted. Ms. ___ underwent a bedside incision and
drainage of the left breast abscess. She had twice daily wet to
dry dressing changes and was discharged home on ___ with
services for dressing changes at home. Ms. ___ remained
afebrile and stable during her hospitalization. Wound cultures
grew pan sensitive staph and she was discharged home with PO
Dicloxacillin.
Discharge Medications:
1. DiCLOXacillin 500 mg PO Q6H
Follow up with your outpatient doctor within 10 days to
determine if you need longer treatment.
RX *dicloxacillin 500 mg 1 capsule(s) by mouth every 6 hours
Disp #*56 Capsule Refills:*0
2. Ibuprofen 600 mg PO Q8H:PRN pain
do not take more than prescribed. Take with food.
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 8 hours Disp
#*40 Tablet Refills:*1
3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN Pain
Do not drive. Do not take more than 4000mg tylenol
(acetaminophen) per day.
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth 30
minutes prior to dressing change Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
breast abscess
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 while you were at ___.
You were admitted with a breast abscess and recieved IV
medication to treat your abscess. You also recieved drainage by
radiology and surgical treatment by the breast surgery team. You
were found to have an infection with staph (MSSA). You were felt
to be safe to be discharged and should follow up with your
outpatient docotor and continue taking antibiotics and dressing
changes as prescribed.
Followup Instructions:
___
|
10144359-DS-12 | 10,144,359 | 27,402,483 | DS | 12 | 2151-03-08 00:00:00 | 2151-03-08 17:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Fever and Intoxication
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ homeless man with HIV/AIDS (CD4 ___K on ___, disseminated ___ infection, h/o PCP (MAC
biopsy proven), HCV genotype 1a VL (undetectable viral load
___, polysubstance abuse, and right meningioma presenting
with alcohol intoxication and fever.
The patient endorses bilateral leg swelling as well. Denies
complete ROS otherwise. Patient states that he drank 0.5L of
hard alcohol today, shot up 0.5g of heroin.
In the ED, initial vitals were: 100.2 85 135/85 15 100% RA
Exam notable for: Very intoxicated. Left eye exotropia (at
baseline per patient); feet exam normal bilaterally;black
macules throughout legs and on tongue; reportedly has had these
for 3 months; heroin needle in left sock
Labs notable for: WBC 3.1 (90N) H/H 7.4/25.1, pl 133; ALT 16,
AST 40, AP 156, LDH 314; Serum EtOH 91; Urine tox positive for
opiates and cocaine; lactate 2.4.
Imaging notable for:
- CXR (___): No clear consolidation
Patient was given:
___ 00:35 IVF 1000 mL NS 1000 mL
LP was performed, WBC 2, other results pending.
Vitals prior to transfer: 98.4 76 122/76 18 100% RA
On the floor, the patient said that he did not have any pain,
but he otherwise declined to speak to the examiner.
ROS: As per HPI.
Past Medical History:
HIV/AIDS CD4 30 in ___ at ___; prior opportunistic infections
include PCP PNA, disseminated ___
HCV genotype 1a VL (undetectable viral load ___
EBV viremia
HBV ___: core antigen (-), core antibody (+), surface
antibody (-), surface antigen (-))
Cocaine abuse
Opioid abuse
EtOH abuse
Bipolar disorder
Depression
G6PD deficiency
Gout
Social History:
___
Family History:
Mother and father with history of cancer
Physical Exam:
ADMISSION EXAM:
===============================
Vital Signs: 98.9 132/8 51 16 100% RA
General: Sleeping but arousable
HEENT: Patient declined exam
CV: RRR, no murmurs
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: BS+, soft, NTND
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Sleeping but arousable
Access: PIV
DISCHARGE EXAM:
===============================
VS: Tm 98.5 Tc 98.0 BP 119/76 HR 78 RR 18 O2 100% on RA
GENERAL: NAD. Sitting up and energetic. Pleasant. Just ate
breakfast.
HEENT: NC/AT. Neck supple with L cervical LAD just lateral to
the trachea. Mucous membranes moist, PERRL oropharynx clear with
multiple dark patches on the tongue
HEART: RRR, no m/r/g
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
ABDOMEN: BS+, soft, NTND
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Warm, dry, intact. Track marks present on the right
forearm. No evidence skin infections. There are multiple dark
patches over the patient's thorax and shoulders. Patient with
increased TTP over old track mark in the right lower extremity
just medial to the tibia, and a thin track underneath the skin
can be felt, today with surrounding erythema and warmth.
- LLE biopsy site well dressed, c/d/i
NEURO: AOx3, CNII-XII grossly intact
Pertinent Results:
ADMISSION LABS:
=================================
CBC:
___ 11:30PM WBC-3.1* RBC-2.90* HGB-7.4* HCT-25.1* MCV-87
MCH-25.5* MCHC-29.5* RDW-17.9* RDWSD-56.6*
CHEM:
___ 11:30PM GLUCOSE-55* UREA N-14 CREAT-1.0 SODIUM-135
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-20* ANION GAP-18
___ 07:21AM ALT(SGPT)-16 AST(SGOT)-50* LD(LDH)-316* ALK
PHOS-164* TOT BILI-0.4
URINE:
___ 11:45PM URINE RBC-2 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 11:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
TOX:
___ 11:30PM ASA-NEG ETHANOL-91* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 11:45PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS*
cocaine-POS* amphetmn-NEG oxycodn-NEG mthdone-NEG
COAGS:
___ 03:49AM ___ PTT-33.2 ___
PERTINENT LABS:
=================================
CBC DIFF:
___ 06:50AM BLOOD Neuts-49.9 ___ Monos-13.8*
Eos-4.6 Baso-0.9 Im ___ AbsNeut-1.09* AbsLymp-0.66*
AbsMono-0.30 AbsEos-0.10 AbsBaso-0.02
___ 07:21AM BLOOD WBC-2.1*# Lymph-26 Abs ___ CD3%-75
Abs CD3-411* CD4%-10 Abs CD4-52* CD8%-59 Abs CD8-324
CD4/CD8-0.16*
LIVER:
___ 07:21AM BLOOD ALT-16 AST-50* LD(LDH)-316* AlkPhos-164*
TotBili-0.4
___ 06:50AM BLOOD ALT-20 AST-48* LD(LDH)-284* AlkPhos-197*
TotBili-0.5
___ 07:35AM BLOOD ALT-18 AST-34 LD(LDH)-250 AlkPhos-176*
TotBili-0.5
MICROBIOLOGY:
=================================
HEPATITIS:
___ 07:35AM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Positive* HAV Ab-Positive IgM HAV-Negative
VIRAL (OTHER):
CMV Viral Load (Final ___: CMV DNA not detected.
EBV:
Test Result Reference
Range/Units
SOURCE Whole Blood
EBV DNA, QN PCR 427 H <200 copies/mL
IMAGING:
=================================
RLE US (___):
1. No evidence of retained needle.
2. Superficial noncompressible vein with thrombus deep to the
area of pain consistent with superficial thrombophlebitis.
RUQ US (___):
1. Normal abdominal ultrasound. Simple right renal cyst.
TTE ___:
1. Regional left ventricular systolic dysfunction c/w CAD.
Normal right ventricular cavity size and systolic function. Mild
mitral regurgitation.
DISCHARGE LABS:
=================================
No discharge labs as patient was stable and just waiting for
discharge placement.
Brief Hospital Course:
Mr. ___ is a ___ homeless man with HIV/AIDS (CD4 ___K on ___, h/o disseminated ___ infection, h/o
PCP (MAC biopsy proven), HCV genotype 1a VL (undetectable viral
load ___, polysubstance abuse, and right meningioma who
presented with alcohol intoxication and fever. The patient did
well with low CIWA scores, not requiring any intervention. He
was found to have both superficial thrombophlebitis in the right
lower extremity, as well as mild EBV viremia and HBV in window
period, all of which could have been contributing to his low
grade fevers. He was afebrile in the hospital within 24 hours of
admission. Blood and urine cultures were negative. Derm was
consulted to biopsy one of the dark patches on his skin and
tongue, and preliminary pathology results were negative for
Kaposi Sarcoma. ID was also consulted and resumed his ART and
antibiotic prophylaxis regimen. Low back pain developed on the
last weekend of admission with spinal and paraspinal muscle
point tenderness. MRI ruled out infection with a very small area
of epidural enhancement, likely inflammation, but unable to rule
out infection completely. It also showed degenerative changes
explaining his musculoskeletal pain. ID agreed this was likely
not infection, did not need to be treated and agreed that he
could have a follow up MRI in one month. He was given diclofenac
cream for his muscular pain.
His problems were assessed, diagnosed, and treated as follows:
ACTIVE PROBLEMS:
=============================
#POLYSUBSTANCE ABUSE with IVDU:
Patient has longstanding history of polysubstance abuse. CIWA
went to 0 and was taken off protocol. No seizures. Gave folate,
thiamine and multivitamin supplementation. Patient was
discharged to ___ Stay-in-bed for 2 weeks with the
intention to go to ___ afterwards, which is a program
with nursing attendants but patient is required to take own
medications. At time of discharge, patient agreeable to
discharge plan.
#FEVER:
Immunocompromised man who presented with temperature elevated to
100.2 in ED, and then 100.5 overnight once. Otherwise afebrile.
CXR clear. LP performed in ED and CSF studies and cultures
unremarkable. HBV core antibody positive but antigen negative,
appearing to be in window period. Fever likely due to EBV
viremia, alcohol withdrawal and superficial thrombophlebitis
that improved over the course of his admission.
#BACK PAIN:
New over the weekend just before discharge. Likely
musculoskeletal as the patient had left low back paraspinal
muscle point tenderness, but endorsed questionable spinal bony
tenderness on day prior to discharge, which improved. Given IVDU
and AIDS, lumbar MRI obtained and was remarkable for
degenerative changes likely explaining his low back pain, no
overt osteomyelitis, discitis, or abscess, but a very small
enhancement that was not able to 100% be ruled out for
infection. ID felt this did not need to be treated given that
patient was clinically well. Plan for MRI follow up in 1 month
(or sooner if symptoms) to ensure resolution or non-progression.
Pain had started to improve on day of discharge.
#HIV/AIDS:
CD4 ___K on ___. Poor and unclear adherence with
ART therapy. Continued Truvada + dolutegravir per ID. Continued
atovaquone (which patient refused to take) and azithromycin ppx.
#SKIN LESIONS:
There was concern for Kaposi Sarcoma. Per derm, preliminary
biopsy results are post inflammatory changes and not concerning
for Kaposi. However, further staining pending and final report
was not yet available on discharge.
STABLE/CHRONIC PROBLEMS:
=============================
#THROMBOPHLEBITIS:
Non-suppurative. Painful narrow tracking induration noted on
physical exam at recent injection site with surrounding erythema
and warmth. No antibiotics necessary given negative blood
cultures. Improved during his stay.
#ELEVATED ALKALINE PHOSPHATASE:
Increased since admission and worked up for biliary obstruction
with RUQ ultrasound which was negative. Likely explained by
positive viral studies. All other liver enzymes trended down
into normal ranges and no more labs were ordered.
#CAD: per patient, prior MI with wall motion abnormalities on
TTE. Started on ASA, statin which he was agreeable to and seen
by cardiology. recommend outpatient stress test.
TRANSITIONAL ISSUES:
===================================
PATIENT CELLPHONE #: ___
PATIENT BROTHER (PROXY) PHONE #: ___
- If febrile or clinical status worsens, please send blood and
urine cultures, and repeat Lumbar MRI with and without contrast
to make sure the small enhancement noted on this admission has
not actually become an infection.
Cardiac:
- Patient noted to have likely CAD given wall motion
abnormalities on echocardiogram and PCP should consider stress
test
- Patient started on atorvastatin 40 mg and ASA 81 mg given echo
findings
Infectious Disease:
- Patient re-started on ART (Truvada + dolutegravir) as well as
Atovaquone (allergic to Bactrim) and Azithromycin ppx here per
ID, which he had been non-compliant with prior to admission
- MRI in one month to follow up on the small epidural
enhancement here.
- Need to follow up on his pending final skin biopsy, which had
a preliminary read of reactive skin changes but NOT Kaposi
Sarcoma
Medically stable for discharge.
> 30 minutes spent on discharge day services, counseling and
coordination of care
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Azithromycin 1200 mg PO 1X/WEEK (MO)
2. Dolutegravir 50 mg PO DAILY
3. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
6. Atovaquone Suspension 750 mg PO DAILY
7. ValACYclovir 500 mg PO Q12H
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every six (6) hours Disp #*30 Tablet Refills:*2
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
3. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
4. diclofenac sodium 3 % topical BID:PRN back pain
RX *diclofenac sodium 3 % Apply where you have back pain twice a
day Refills:*2
5. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone 750 mg/5 mL 2 packets by mouth once a day
Refills:*2
6. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
RX *dextran 70-hypromellose (PF) [Natural Tears (PF)] 0.1 %-0.3
% 1 drops eye three times a day Disp #*1 Bottle Refills:*2
7. Azithromycin 1200 mg PO 1X/WEEK (MO)
RX *azithromycin 600 mg 2 tablet(s) by mouth once a week Disp
#*30 Tablet Refills:*2
8. Dolutegravir 50 mg PO DAILY
RX *dolutegravir [Tivicay] 50 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*2
9. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
RX *emtricitabine-tenofovir [Truvada] 100 mg-150 mg 1 tablet(s)
by mouth once a day Disp #*30 Tablet Refills:*2
RX *emtricitabine-tenofovir [Truvada] 200 mg-300 mg 1 tablet(s)
by mouth once a day Disp #*30 Tablet Refills:*2
10. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*2
11. ValACYclovir 500 mg PO Q12H
RX *valacyclovir 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*2
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
- HIV/AIDS
- POLYSUBSTANCE ABUSE (ALCOHOL, OPIOID, COCAINE)
- FEVER
- THROMBOPHLEBITIS (NON-SUPPURATIVE)
- CORONARY ARTERY DISEASE
- LOW BACK PAIN
SECONDARY:
- DEPRESSION
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you had a fever and
were intoxicated
We watched you closely as your body cleared the alcohol and
drugs out to make sure that you didn't have seizures. We looked
for viruses, bacteria, and yeast in your blood to figure out why
you had fever and found that you have a virus called EBV and
Hepatitis B, but no bacterial or fungal infections. We also
checked your HIV levels and found that the amount of HIV in your
blood right now is very high and that your white blood cells
called T cells are very low
There were a few other abnormalities we saw during this
hospitalization and did tests for:
- Because of the new dark patches on your skin, we performed a
biopsy of one of the patches and found that they are not
anything concerning.
- Because you had a painful hard vein in your leg, we did an
ultrasound to see if there was a broken off needle there. We
found a small clot there, but no needle.
- We performed an ultrasound of your heart which showed that it
isn't working as well as it should be which is consistent with
your previous heart attack, and gave you aspirin and a statin to
treat this.
- You had low back pain with a tender spine, and we did an MRI
to make sure you did not have an infection in your spine which
can happen with people who us IV drugs. We did not find an
infection. Your back pain is probably from a bulging disk, and
we gave you anti-inflammatory cream to treat this.
When you leave the hospital, you should:
- Stay at the facility where you are sent and work on staying
away from drugs and alcohol
- Talk to friends and family regularly, they are your best
support system!
- Take your antibiotics and HIV medications regularly, they will
protect you. (Especially Mepron, even if it tastes bad. This
protects you from a very serious type of pneumonia that you can
get with HIV)
- Take the new medications for your heart which are atorvastatin
and a baby aspirin
- Use your anti-inflammatory cream called diclofenac to treat
your back pain
It was a pleasure taking care of you,
Your ___ Team
Followup Instructions:
___
|
10144359-DS-13 | 10,144,359 | 27,987,310 | DS | 13 | 2151-03-22 00:00:00 | 2151-03-22 15:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
leg pain
Major Surgical or Invasive Procedure:
___: PICC placement
___: CT guided bone biopsy of L4 facet with ___
___: CT guided aspiration of L4-L5 facet joint fluid
collection with ___
History of Present Illness:
___ HIV/AIDs (CD4 52, VL 124K on ___, h/o disseminated
___, h/o PJP, HCV, polysubstance abuse, R meningioma with recent
hospitalization ___ presenting with R leg pain x 3 days.
The ED physician observed ___ cardiac murmur and was concerned for
the possibility of endocarditis given signs of skin infection,
immunosuppressed state and possible murmur. THe patient's blood
was cultured and he received vancomycin.
During his recent hospitalization he had findings of superficial
thrombophlebitis in the right lower extremity as well as mild
EBV viremia and HBV in the window period all of which may have
explained his fever.
He says he is more bothered by his low back pain which is more
present on the L and mid-line than on the right and causes him
to limp. The pain is sharp and does not radiate. He has not
had changes in bowel or bladder habits. Pain is severe.
ROS:
he has had sweats, fatigue and cough, he has low back pain as
above, no nausea/vomiting/diarrhea or abdominal pain, no new
rashes or skin or lip changes, no weight loss or objective
fevers, no new headache, chest pain, SOB with activity, no new
confusion or mood changes and 13pt is otherwise negative
Past Medical History:
HIV/AIDS CD4 30 in ___ at ___; prior opportunistic infections
include PCP PNA, disseminated ___
HCV genotype 1a VL (undetectable viral load ___
EBV viremia
HBV ___: core antigen (-), core antibody (+), surface
antibody (-), surface antigen (-))
Cocaine abuse
Opioid abuse
EtOH abuse
Bipolar disorder
Depression
G6PD deficiency
Gout
summary included in recent ID note
ID BRIEF SUMMARY OF MEDICAL+SOCIAL HISTORY PER ___ RECORDS
(per notes of ID physician ___ from ___
HIV/AIDS: Dx approx ___
ARV/OI HISTORY
-___ unknown ART, if any, followed off and on at ___
-___: PCP and MAC (dx by intra-abd LN biopsy), started ART with
TDF/FTC + RAL --> TDF/FTC + DRV/r to increase barrier to
resistance (given h/o longstanding nonadherence), took for a
couple of months, cleared MAC from blood cultures and then fell
out of care
-___: mostly out of care and off all ART, took TDF/FTC
+DTG intermittent for brief periods
-other OI's: oral candidiasis
RESISTANCE TESTING
___: RT =69D, 69N; no PI mutations
___: Genotype = no mutations; integrase genotype =163E--> no
resistance predicted
RECENT LAB HISTORY
___ CD4 17, VL ___
___ CD4 15 (3%), L ___ VL ___
___ CD4 202, VL ___ CD4 30, VL ___ CD4 66 VL ___
___ CD4 85 VL 146
OTHER PAST MEDICAL HISTORY
HCV Ab positive, VL negative for some time, 22 in ___
Polysubstance abuse (EtOH, crack/cocaine, heroin previously on
methadone but not currently)
Mood disorder (possible bipolar disorder, mood lability and
anger)
Personality disorder
G6PD deficiency
h/o PCP pneumonia, MAC, ___, oral candidiasis
Gout
Meningioma
Staph marginal keratitis ___
h/o MRSA abscess of arm
ID HEALTH MAINTENANCE ISSUES
-HepBCAb pos, HBSAAb pos, HBSAg neg
-HCV AB pos, VL ___ (plan for q6mo VL)
-Syphilis screen neg ___
-VZV IgG pos ___
-Toxo IgG: neg ___
-CMV IgG pos ___
-TSpot neg ___
-Vaccines: Pneumovax last ___, due ___ never given Prevnar;
Td/TDAP last ___, due ___
SOCIAL HISTORY
SW at ___: ___ at ___ clinic
-H/o being barred from many residential drug/alcohol treatment
programs and respite care and halfway house programs d/t
inappropriate behavior
-Substance abuse as above
-Pt homeless for many years; has many siblings, some of which
have attempted to help/intervene
Social History:
___
Family History:
Mother and father with history of cancer
Physical Exam:
ADMISSION PHYSICAL:
====================
98.3 143/96 82 18 100RA
aox3 calm and attentive
several hypopigmented nodules on lower lip
clear BS, no wheezes or crackles
soft ___ flow murmur in systole in RUSB
no audible murmurs in apex and no diastolic regurgitant murmurs
observed
soft abdomen with midline scar
raised cord like vein superficial R upper leg, without severe
discomfort to palpation, no redness, warmth or superficial
swelling or fluctuance
lower l4-l5 midline low back pain, also pain in L paraspinal
region to palpation
requires extra effort and discomfort to raise L leg off bed,
able to fully extend/flex at L and R ankles bilaterally equally
no deficit to light touch
hyperpigmented lesion at site of skin biopsy clean and dry
covered by dressing
mood calm
DISCHARGE PHYSICAL:
====================
VITALS: 98.3 PO 142 / 89 66 16 100 ra
GEN: NAD, pleasant, interactive
HEENT: EOMI, sclerae anicteric, MMM, dark lesions on right
lateral tongue stable
NECK: No JVD
CARDIAC: RRR, no M/R/G
PULM: CTAB, good air movement
GI: soft, NT, ND, NABS
NEURO: AAOx3. ___ strength in bilateral lower extremities normal
sensation in bilateral lower extremities
PSYCH: flat affect
EXTREMITIES: WWP, no edema, deformity of left shin from prior
fracture with rod placement
Pertinent Results:
___ MRI L spine w/ and w/o contrast:
FINDINGS:
When compared to examination ___, there is
interval increase
conspicuity of a peripherally enhancing fluid collection arising
from the left L4-L5 facet joint, with associated surrounding
enhancing soft tissue and increased enhancing facet marrow edema
pattern, not seen on prior examination. In addition, increased
enhancing edema pattern of the adjacent paraspinal muscles
extending up to the L1 level is concerning for either reactive
or infectious myositis. No evidence for intramuscular abscess
at this time. No epidural rim enhancing collection to suggest
epidural abscess.
Lumbar alignment is anatomic. Vertebral body heights are
preserved. T12
superior endplate Schmorl's node with adjacent marrow edema
pattern is similar in appearance to examination of ___ without evidence of adjacent disc signal abnormality,
almost certainly degenerative in nature. No abnormal enhancing
T2 hyperintense signal of the discs to suggest discitis. The
remainder of the marrow signal is within expected limits. The
conus medullaris terminates at the L1 level, within expected
limits. There is no abnormal signal or enhancement of the
terminal cord, conus medullaris or cauda equina. Chronic
fracture of the left L2 transverse process is noted.
L1-L2 and L2-L3: Small disc bulges do not significantly narrow
the spinal
canal or result in significant neural foraminal narrowing.
L3-L4: A disc bulge with minimally inferiorly migrating left
disc fragment, similar appearance to prior examination, which
crowds the left subarticular zone without significant spinal
canal narrowing. There is associated unchanged epidural
enhancement without rim enhancement, presumably inflammatory in
nature. In combination with facet arthropathy, there is mild
left and no significant right neural foraminal narrowing.
L4-L5: A small disc bulge does not significantly narrow the
spinal canal. There is no significant neural foraminal
narrowing. The no evidence for epidural fluid collection or
definitive phlegmon.
L5-S1: No significant spinal canal or neural foraminal
narrowing.
The visualized prevertebral soft soft tissues are unremarkable.
IMPRESSION: 1. When compared to examination 5 days prior, there
is increased conspicuity of peripherally enhancing fluid
collection arising from the left L4-L5 facet joint with
worsening associated surrounding enhancing soft tissue and
increasing enhancing facet marrow edema, highly concerning for
septic joint.
2. Associated enhancing paraspinal soft tissue edema extending
to the L1
level, may represent reactive versus infectious myositis.
3. No evidence for epidural abscess or definitive evidence for
epidural
phlegmon at this time.
4. There is STIR hyperintense signal of the T12 superior
endplate, presumably degenerative secondary to a endplate
Schmorl's node, however close attention on followup is
recommended. No evidence of discitis.
5. Additional findings described above.
TTE ___:
Left ventricular wall thicknesses and cavity size are normal.
There is mild regional left ventricular systolic dysfunction
with hypokinesis of the mid to distal inferolateral wall. There
is mild hypokinesis of the remaining segments (LVEF = 45 %) best
appreciated in clips 50 and 54. There is considerable
beat-to-beat variability of the left ventricular ejection
fraction due to an irregular rhythm/premature beats. 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) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. No
masses or vegetations are seen on the aortic valve. The mitral
valve leaflets are structurally normal. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve.
Mild (1+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
IMPRESSION: Frequent PVCs. Possible PVC related cardiomyopathy
with mild global hypokinesis. The inferolateral wall does appear
more densely hypokinetic suggesting possible overlapping CAD. No
2D echo evidence of endocarditis on a high quality study. Mildly
dilated ascending aorta. Mild pulmonary hypertension.
Compared with the prior study (images reviewed) of ___
the pulmonary pressures are higher. Overall hypokinesis appears
more global.
___ MRI T and C spine:
FINDINGS:
The images are severely degraded by motion.
CERVICAL:
Alignment is normal.Vertebral body heights are preserved. There
is no bone marrow signal abnormality. There is diffuse loss of
disc height and normal T2 signal in the cervical spine.
There is no high-grade spinal canal or neural foraminal
narrowing at C2-3 and C3-4.
At C4-5, there is a posterior disc protrusion and uncovertebral
osteophytes resulting in mild spinal canal and mild bilateral
neural foraminal narrowing.
At C5-6, there is a posterior disc protrusion and uncovertebral
osteophytes, resulting in moderate spinal canal and moderate
bilateral neural foraminal narrowing.
At C6-7, there is a posterior disc protrusion and uncovertebral
osteophytes, resulting in mild spinal canal and mild bilateral
neural foraminal narrowing.
The spinal cord appears normal and signal intensity. The
postcontrast axial images are nondiagnostic as a result of
motion artifact. The postcontrast sagittal images are also
motion degraded. Within this limitation, there is no obvious
abnormal enhancement. The paraspinal soft tissues are within
normal limits. There is no epidural or paraspinal fluid
collection
THORACIC:
Alignment is normal.Vertebral body heights are preserved. There
is a mildly enhancing T2 hypointense, mildly T2 hyperintense
lesion in the T12 vertebral body (12:10) that likely reflects
___ type 1 change. There is no disc herniation. There is no
spinal canal or neural foraminal narrowing. Evaluation of the
spinal cord is limited by motion artifact on the sagittal and
axial T2 weighted images. The spinal cord appears normal in
caliber.Postcontrast images are degraded by artifact. There is
no paraspinal soft tissue abnormality.
IMPRESSION:
1. The study is at least moderately degraded by motion, limiting
assessment of the spinal cord and detection of enhancing
lesions.
2. A mildly enhancing T1 hypointense lesion in the T12
vertebral body is
likely ___ type 1 signal intensity change related to
degenerative disc
disease.
3. Multilevel degenerative changes as described above.
4. No evidence of discitis or osteomyelitis in the cervical and
thoracic
spine.
Portable CXR ___: In comparison to ___ chest
radiograph, a right PICC has been placed, terminating in the
lower superior vena cava. Cardiomediastinal contours are
stable, and lungs are grossly clear except for minor atelectasis
at the lung bases.
ADMISSION LABS:
==================
___ 04:25AM BLOOD WBC-3.7* RBC-3.08* Hgb-7.6* Hct-26.0*
MCV-84 MCH-24.7* MCHC-29.2* RDW-17.4* RDWSD-53.9* Plt ___
___ 04:25AM BLOOD Neuts-48.9 ___ Monos-19.4*
Eos-6.7 Baso-0.8 Im ___ AbsNeut-1.82# AbsLymp-0.86*
AbsMono-0.72 AbsEos-0.25 AbsBaso-0.03
___ 04:25AM BLOOD Glucose-103* UreaN-17 Creat-1.0 Na-135
K-4.9 Cl-100 HCO3-24 AnGap-16
CRP: 61.7
Interval labs:
=================
___ 07:45AM BLOOD WBC-5.6# RBC-3.04* Hgb-7.7* Hct-25.0*
MCV-82 MCH-25.3* MCHC-30.8* RDW-17.3* RDWSD-51.7* Plt ___
___ 09:50AM BLOOD WBC-3.1* RBC-3.46* Hgb-8.6* Hct-28.3*
MCV-82 MCH-24.9* MCHC-30.4* RDW-16.9* RDWSD-50.6* Plt ___
___ 08:00AM BLOOD WBC-2.7* RBC-3.20* Hgb-8.0* Hct-26.8*
MCV-84 MCH-25.0* MCHC-29.9* RDW-17.0* RDWSD-52.5* Plt ___
___ 05:55AM BLOOD Neuts-67 Bands-2 Lymphs-12* Monos-11
Eos-7 Baso-0 ___ Metas-1* Myelos-0 AbsNeut-1.59*
AbsLymp-0.28* AbsMono-0.25 AbsEos-0.16 AbsBaso-0.00*
___ 07:45AM BLOOD Glucose-81 UreaN-14 Creat-0.8 Na-135
K-3.8 Cl-102 HCO3-25 AnGap-12
___ 09:23PM BLOOD Glucose-83 UreaN-16 Creat-1.5* Na-133
K-4.3 Cl-97 HCO3-24 AnGap-16
___ 05:55AM BLOOD Glucose-86 UreaN-11 Creat-1.0 Na-140
K-3.8 Cl-108 HCO3-26 AnGap-10
___ 09:23PM BLOOD ALT-19 AST-46* AlkPhos-184* TotBili-0.2
DirBili-<0.2 IndBili-0.2
___ 07:15AM BLOOD calTIBC-328 VitB12-400 Ferritn-19*
TRF-252
___ 07:15AM BLOOD Iron-20*
Discharge Labs:
==================
___ 06:00AM BLOOD WBC-2.6* RBC-3.08* Hgb-7.7* Hct-25.6*
MCV-83 MCH-25.0* MCHC-30.1* RDW-17.2* RDWSD-53.0* Plt ___
___ 06:00AM BLOOD Neuts-42 Bands-0 ___ Monos-12
Eos-14* Baso-0 ___ Myelos-0 AbsNeut-1.09*
AbsLymp-0.83* AbsMono-0.31 AbsEos-0.36 AbsBaso-0.00*
___ 06:00AM BLOOD Glucose-90 UreaN-8 Creat-1.0 Na-139 K-4.0
Cl-107 HCO3-24 AnGap-12
___ 06:00AM BLOOD CRP-19.6*
___ 05:55AM BLOOD Vanco-7.0*
MICROBIOLOGY:
================
Blood culture ___: coag negative staph
Blood culture ___ x2: Negative
Blood cultures ___ x2: Negative
___: RPR negative
___: Mycolytic blood cultures: ___
___: Bone biopsy from L4 facet joint: Gram stain negative, ___
___: Sputum for PCP: ___
Brief Hospital Course:
___ M with history of HIV/AIDS(last CD4 count of 52 in early
___ on HAART, active substance abuse with cocaine
and opiates with persistent low back pain with low grade fever
and night sweats now found to have imaging findings on MRI
suggestive of L4-L5 facet joint infection.
#Septic arthritis of Lspine: MRI showed peripherally enhancing
fluid collection in facet joint of L4-L5 concerning for septic
joint in the setting of expansion of fluid collection compared
with MRI earler in the month. Fluid aspiration was attempted by
___ on ___ with minimal fluid return. Bone biopsy of L4 facet
joint performed with CT guidance on ___ with negative gram
stain, cultures pending. All blood cultures ___ (other than 1
bottle coag neg staph ___ as below) and TTE without vegetation.
Given that concern was for septic arthritis without organism
identified in immunocompromised patient, he was started on
vancomycin and ceftriaxone on ___. Vanc trough 7 on ___
however in setting of changing renal function. Reassuringly, his
CRP improved to 19.6 from 61 on discharge after initiation of
antibiotics and he has had significant improvement in his pain
needed rare dilaudid. Per ID here, will likely need ___ weeks of
antibiotic therapy with complete duration pending repeat MRI at
that time to assess resolution in fluid collection and bone
changes. Prior to discharge, universal PCR of bone biopsy sent
for evaluation of cause of infection, result pending at
discharge.
#Low back pain: Patient reported severe back pain on admission
limiting mobility. He was seen by the chronic pain service who
initiated gabapentin, naproxen, prn cyclobenzaprine and prn
trazadone as well as PO dilaudid. His dilaudid was tapered on
___ to 6mg q6h prn with good effect and he was ambulating
without difficulty prior to discharge. His dilaudid should
continue to be tapered over the next ___ weeks.
#Polysubstance abuse: Patient has history of heroin and cocaine
abuse. Used while inpatient on ___ ___. He reported desire to
start methadone and maintain sobriety moving forward. Please
assist patient with initiation of methadone and addiction
management at ___.
#Leukopenia: Felt to be related to infection and HIV. Stable
throughout hospitalization with ANC 1100 prior to discharge.
#Anemia: Patient had history of significant anemia. Found to
have iron deficiency this admission. Started on PO iron
supplementation.
___: Patient had brief bump in creatinine to 1.5 from 1.0 on
___ which resolved with 1L normal saline.
#Coag negative staph bacteremia: Patient had coag negative staph
in ___ blood culture bottles from ___ which were felt to be a
contaminant. His subsequent blood cultures were negative.
#HIV/AIDS: Last CD4 count 52 ___. Patient was continued on
truvada and dolutegravir. For prophylaxis, he was continued on
azithromycin weekly, valacyclovir and atovaquone. Patient
continuously refused atovaquone for PCP ___. Due to
Bactrim allergy, G6PD was sent. If negative, could transition to
dapsone for PCP ___ (pending at discharge). I continued
to reiterate to patient the importance of taking atovaquone to
prevent PCP. Of note, patient had mild cough on ___ for which
sputum culture was sent for PCP however CXR negative and cough
resolved on ___.
#AMS: Patient with AMS on ___ evening (___) in the setting
of using, reportedly snorted heroin overnight. His room was
searched with no further drugs in his room. He was not allowed
any further visitors following this incident. His mental status
returned to baseline by ___.
#HLD: Patient continued on atorvastatin during admission.
#Primary Cardiac prophylaxis: Patient continued on aspirin 81mg
daily.
#Cardiomyopathy: Patient had TTE during admission to evaluate
for endocarditis which was negative for vegetation however
showed global hypokinesis with EF of 45% consistent with
cardiomyopathy possibly from PVCs vs from cocaine use. Will need
outpatient cardiology follow-up on discharge. He was started on
low dose lisinopril in house (2.5mg daily).
TRANSITIONAL:
===============
[]Please repeat CBC with diff on ___ to evaluate for
improvement in leukopenia, rule out neutropenia.
[]Please arrange outpatient cardiology follow-up on discharge
for evaluation of cardiomyopathy. Consider initiation of
metoprolol as outpatient.
[]Please check vancomycin trough on ___ prior to AM dose (goal
___
[]Will need arrangement of HIV continuity care on discharge from
___
[]Please follow-up G6PD, transition to dapsone if negative due
to patient preference
[]follow-up sputum from ___ for PCP
[]f/u tissue culture (bone biopsy) from ___
[]f/u blood cultures from ___
[]Please taper dilaudid off over next ___ weeks based on chronic
pain recs
[]Please work with patient to initiate methadone maintenance
given desire to treat his addiction and maintain sobriety
[]Plan is for ___ weeks of IV antibiotics (Day 1 = ___, will
need repeat imaging (MRI) prior to discontinuation of
antibiotics.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
2. Atovaquone Suspension 1500 mg PO DAILY
3. Azithromycin 1200 mg PO 1X/WEEK (MO)
4. Dolutegravir 50 mg PO DAILY
5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. ValACYclovir 500 mg PO Q12H
8. Acetaminophen 650 mg PO Q6H
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 40 mg PO QPM
11. diclofenac sodium 3 % topical BID:PRN back pain
Discharge Medications:
1. CefTRIAXone 2 gm IV Q24H
2. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm/pain
3. Ferrous Sulfate 325 mg PO DAILY
4. Gabapentin 300 mg PO TID
5. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN Pain - Moderate
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
six (6) hours Disp #*10 Tablet Refills:*0
6. Lisinopril 2.5 mg PO DAILY
7. Naproxen 500 mg PO Q12H
8. Nystatin Cream 1 Appl TP BID
9. TraZODone 50 mg PO QHS:PRN insomnia
10. Vancomycin 1000 mg IV Q 12H
11. Acetaminophen 1000 mg PO Q8H
12. ValACYclovir 1000 mg PO Q8H
13. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
14. Aspirin 81 mg PO DAILY
15. Atorvastatin 40 mg PO QPM
16. Atovaquone Suspension 1500 mg PO DAILY
17. Azithromycin 1200 mg PO 1X/WEEK (MO)
18. Dolutegravir 50 mg PO DAILY
19. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
20. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnoses:
====================
septic arthritis of lumbar facet joint
Acute Kidney Injury
Secondary diagnoses:
=====================
hiv/aids
iron deficiency anemia
Leukopenia
Cardiomyopathy
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 with low back pain and low
grade fevers. You had a repeat MRI which showed evidence of an
infection in one of the joints in your spine. You had two
procedures to attempt to identify the cause of your infection.
These cultures are still pending. You had a PICC line placed and
were started on two different antibiotics, Vancomycin and
Ceftriaxone. You will likely need to continue these for at least
___ weeks. You are being discharged to the ___ for
ongoing antibiotic management.
While you were here, you were seen by the chronic pain service
for your back pain and started on several medications for your
pain. You will be discharged on a taper of these medications.
You also expressed to us that you were interested in trying
manage your addiction with the initiation of methadone. You
should be able to start methadone at the ___.
It is really important that you continue to take all of your
medications as prescribed. We are working on finding an
alternative to atovaquone but in the mean time, it is important
that you continue to take this to prevent infections.
It was a pleasure taking care of you,
Your ___ Care Team
Followup Instructions:
___
|
10144359-DS-15 | 10,144,359 | 22,065,166 | DS | 15 | 2152-01-16 00:00:00 | 2152-01-16 15:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Fever, Cocaine intoxication
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness
___ year old male with AIDS (CD4 93, VL unknown) who presented
with one day of subjective fever, chills and cough. The patient
also was apparently acutely intoxicated with cocaine on
presentation to the ED.
The patient had temperatures to 100.0 and given the concern of
the patient having AIDS, was started on empiric
vancomycin/zosyn
for an unclear source. A chest xray was performed and was
negative for infiltrate, blood and urine cultures were
obtained.
It is unclear why such broad spectrum antibiotics were started
based on ED documentation as no source was noted. The patient
does have a history of ADIs inclucing PCP, ___. and is
coinfected with HCV. The ED Was initially planning ED Obs when
the patient spiked to 101 in the ED.
Past Medical History
HIV/AIDS CD4 30 in ___ at ___; prior opportunistic
infections
include PCP PNA, disseminated ___
HCV genotype 1a VL (undetectable viral load ___
EBV viremia
HBV ___: core antigen (-), core antibody (+), surface
antibody (-), surface antigen (-))
Cocaine abuse
Opioid abuse
EtOH abuse
Bipolar disorder
Depression
G6PD deficiency
Gout
summary included in recent ID note
ID BRIEF SUMMARY OF MEDICAL+SOCIAL HISTORY PER ___ RECORDS
(per notes of ID physician ___ from ___
HIV/AIDS: Dx approx ___
ARV/OI HISTORY
-___ unknown ART, if any, followed off and on at ___
-___: PCP and MAC (dx by intra-abd LN biopsy), started ART
with
TDF/FTC + RAL --> TDF/FTC + DRV/r to increase barrier to
resistance (given h/o longstanding nonadherence), took for a
couple of months, cleared MAC from blood cultures and then fell
out of care
-___: mostly out of care and off all ART, took TDF/FTC
+DTG intermittent for brief periods
-other OI's: oral candidiasis
RESISTANCE TESTING
___: RT =69D, 69N; no PI mutations
___: Genotype = no mutations; integrase genotype =163E-->
no
resistance predicted
RECENT LAB HISTORY
___ CD4 17, VL ___
___ CD4 15 (3%), L ___ VL ___
___ CD4 202, VL ___ CD4 30, VL ___ CD4 66 VL ___
___ CD4 85 VL 146
OTHER PAST MEDICAL HISTORY
HCV Ab positive, VL negative for some time, 22 in ___
Polysubstance abuse (EtOH, crack/cocaine, heroin previously on
methadone but not currently)
Mood disorder (possible bipolar disorder, mood lability and
anger)
Personality disorder
G6PD deficiency
h/o PCP pneumonia, MAC, ___, oral candidiasis
Gout
Meningioma
Staph marginal keratitis ___
h/o MRSA abscess of arm
ID HEALTH MAINTENANCE ISSUES
-HepBCAb pos, HBSAAb pos, HBSAg neg
-HCV AB pos, VL ___ (plan for q6mo VL)
-Syphilis screen neg ___
-VZV IgG pos ___
-Toxo IgG: neg ___
-CMV IgG pos ___
-TSpot neg ___
-Vaccines: Pneumovax last ___, due ___ never given Prevnar;
Td/TDAP last ___, due ___
SOCIAL HISTORY
SW at ___: ___ at ___ clinic
-H/o being barred from many residential drug/alcohol treatment
programs and respite care and halfway house programs d/t
inappropriate behavior
-Substance abuse as above
-Pt homeless for many years; has many siblings, some of which
have attempted to help/intervene
Social History
Homeless, active IVDU (heroin), cocaine and EtOH abuse. Drink
___ EtOH daily; has experienced EtOH withdrawal in the past but
no prior history of seizure/DT.
Has one daughter that lives nearby.
Proxy name: ___
Relationship: Brother Phone: ___
Family History
Mother and father with history of cancer
Past Medical History:
HIV/AIDS CD4 30 in ___ at ___; prior opportunistic infections
include PCP PNA, disseminated ___
HCV genotype 1a VL (undetectable viral load ___
EBV viremia
HBV ___: core antigen (-), core antibody (+), surface
antibody (-), surface antigen (-))
Cocaine abuse
Opioid abuse
EtOH abuse
Bipolar disorder
Depression
G6PD deficiency
Gout
summary included in recent ID note
ID BRIEF SUMMARY OF MEDICAL+SOCIAL HISTORY PER ___ RECORDS
(per notes of ID physician ___ from ___
HIV/AIDS: Dx approx ___
ARV/OI HISTORY
-___ unknown ART, if any, followed off and on at ___
-___: PCP and MAC (dx by intra-abd LN biopsy), started ART with
TDF/FTC + RAL --> TDF/FTC + DRV/r to increase barrier to
resistance (given h/o longstanding nonadherence), took for a
couple of months, cleared MAC from blood cultures and then fell
out of care
-___: mostly out of care and off all ART, took TDF/FTC
+DTG intermittent for brief periods
-other OI's: oral candidiasis
RESISTANCE TESTING
___: RT =69D, 69N; no PI mutations
___: Genotype = no mutations; integrase genotype =163E--> no
resistance predicted
RECENT LAB HISTORY
___ CD4 17, VL ___
___ CD4 15 (3%), L ___ VL ___
___ CD4 202, VL ___ CD4 30, VL ___ CD4 66 VL ___
___ CD4 85 VL 146
OTHER PAST MEDICAL HISTORY
HCV Ab positive, VL negative for some time, 22 in ___
Polysubstance abuse (EtOH, crack/cocaine, heroin previously on
methadone but not currently)
Mood disorder (possible bipolar disorder, mood lability and
anger)
Personality disorder
G6PD deficiency
h/o PCP pneumonia, MAC, ___, oral candidiasis
Gout
Meningioma
Staph marginal keratitis ___
h/o MRSA abscess of arm
ID HEALTH MAINTENANCE ISSUES
-HepBCAb pos, HBSAAb pos, HBSAg neg
-HCV AB pos, VL ___ (plan for q6mo VL)
-Syphilis screen neg ___
-VZV IgG pos ___
-Toxo IgG: neg ___
-CMV IgG pos ___
-TSpot neg ___
-Vaccines: Pneumovax last ___, due ___ never given Prevnar;
Td/TDAP last ___, due ___
SOCIAL HISTORY
SW at ___: ___ at ___ clinic
-H/o being barred from many residential drug/alcohol treatment
programs and respite care and halfway house programs d/t
inappropriate behavior
-Substance abuse as above
-Pt homeless for many years; has many siblings, some of which
have attempted to help/intervene
Social History:
___
Family History:
Mother and father with history of cancer
Physical Exam:
DISCHARGE EXAM:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without thrush
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored. No crackles.
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM. However with the left flank there is
mild tenderness to palpation.
GU: No suprapubic fullness or tenderness to palpation.
MSK: Neck supple, moves all extremities
PSYCH: flat affect
NEUROLOGIC:
MENTATION: alert and cooperative. PERRL 3 mm b/l pupils. EOMI.
Moves all ext ___ strength throughout.
Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt
Ct
___ 06:45 3.2* 3.61* 9.4* 30.3* 84 26.0 31.0* 15.6*
47.8* 233
T LYMPHOCYTE SUBSET WBC Lymph Abs ___ CD3% Abs CD3 CD4% Abs CD4
CD8% Abs CD8 CD4/CD8
___ 14:53 4.7 21 987 82 807 18 180* 58 576 0.31*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 07:03 ___ 139 3.9 ___
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
___ 07:03 14 34 324* 167* 0.3
DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub
Urobiln pH Leuks
___ 21:00 NEG NEG 30* NEG NEG NEG NEG 6.5 NEG
MICROSCOPIC URINE EXAMINATION ___ Bacteri Yeast Epi TransE
RenalEp
___ 21:00 0 <1 NONE NONE ___ SEROLOGY/BLOOD RPR w/check for
Prozone-PENDING INPATIENT
___ BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
___ BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE-PENDING; BLOOD/AFB CULTURE-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
___ BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
___ BLOOD CULTURE Blood Culture,
Routine-PENDING EMERGENCY WARD
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
___ BLOOD CULTURE Blood Culture,
Routine-PENDING EMERGENCY WARD
___BD & PELVIS WITH CO
INDICATION: ___ year old man with AIDS, known recent L4-L5
septic arthritis
with MAC, presents with L flank pain, fever to 102// Fever with
L flank pain
in immunocompromised patient, eval for intrabdominal infectious
process
TECHNIQUE: Multidetector CT images of the abdomen and pelvis
were acquired
without intravenous contrast. Non-contrast scan has several
limitations in
detecting vascular and parenchymal organ abnormalities,
including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 7.6 s, 49.4 cm; CTDIvol = 5.8 mGy
(Body) DLP = 280.7
mGy-cm.
Total DLP (Body) = 281 mGy-cm.
COMPARISON: MR lumbar spine ___.
FINDINGS:
Lack of IV contrast limits evaluation of solid organs and
vascular structures.
Lack of oral contrast and paucity of intra-abdominal fat limits
assessment of
bowel pathology.
LOWER CHEST: Minimal dependent atelectasis.
HEPATOBILIARY: Unenhanced liver is unremarkable. Gall bladder
is not
visualized.
PANCREAS: Unremarkable pancreas.
SPLEEN: Measures 12.5 cm.
ADRENALS: Unremarkable.
URINARY:No hydronephrosis. No nephrolithiasis. Urinary bladder
is
unremarkable.
GASTROINTESTINAL: Stomach filled with food debris, unremarkable.
Status post
bowel resection and anastomosis. No bowel obstruction. Colonic
diverticulosis.
PERITONEUM: No free air. No free-fluid. No peritoneal
stranding.
LYMPH NODES: No adenopathy.
VASCULAR: Normal caliber abdominal aorta.
PELVIS: Rectum is unremarkable. Unremarkable seminal vesicles.
BONES:No appreciable acute osseus abnormality. The vertebral
body endplates
are maintained.
SOFT TISSUES: Metallic superficial density along the right
medial gluteal
region. Soft tissues are otherwise unremarkable.
IMPRESSION:
No acute intra-abdominal process. Note that evaluation is
somewhat limited
with lack of contrast and paucity of intra-abdominal fat.
___ Imaging CT HEAD W/O CONTRAST
INDICATION: History: ___ with AIDS, AMS// please eval for
bleed, intracranial
lesions
TECHNIQUE: Contiguous axial images of the brain were obtained
without
contrast in standard and soft tissue thins. Coronal and sagittal
reformations
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy
(Head) DLP =
747.2 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: CT head ___ stable.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or
midline shift.
There is a stable 0.8 x 0.8 cm hypodense right occipital lesion,
previously
characterized and meningioma and unchanged in size. There is
persistent
prominence of the ventricles and sulci more than expected for
given age.
Nonspecific periventricular subcortical white matter
hypodensities suggest
chronic small vessel ischemic changes.
There is no evidence of acute fracture. There is moderate
mucosal thickening
of the bilateral maxillary, ethmoid, and sphenoid sinuses. The
visualized
portion of the remaining paranasal sinuses, mastoid air cells,
and middle ear
cavities are clear.
IMPRESSION:
1. No evidence of acute intracranial process such as hemorrhage
or infarction.
2. Stable 0.8 cm right occipital meningioma
___ Imaging CHEST (PA & LAT)
INDICATION: History: ___ with cough, borderline fever, hx of
HIV// r/o PNA
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Mild right base atelectasis is seen without definite focal
consolidation. No
pleural effusion or pneumothorax is seen. Enlargement of the
main pulmonary
artery suggest component of underlying pulmonary hypertension.
Cardiac
silhouette is mildly enlarged.
IMPRESSION:
Enlargement the pulmonary artery suggests underlying pulmonary
hypertension.
No focal consolidation to suggest pneumonia.
Brief Hospital Course:
TRANSITIONAL ISSUES:
-Patient will need continued follow up for HIV/AIDS.
-He will need continued outpatient follow up for chronic HCV
infection (genotype 1a, 4 log10 VL on ___ and isolated HBcAb
positive (___).
===================
HOSPITAL COURSE:
Mr. ___ is a ___ year old homeless gentleman with history of
polysubstance
(IVDA, cocaine, ETOH), HIV/AIDS (CD4 ___ on ___
with recent septic L4 joint arthritis (MAC+ on biopsy), chronic
HCV infection, isolated positive HBcAb ___, reduced LVEF 45%
on ___ TTE, G6PD deficiency (confirmed on ___ assay),
bipolar disorder, HLD who presented with subjective fevers and
left flank pain after being brought by EMS to ___ on ___ for
cocaine intoxication.
In the ED, he had hypoglycemia and fever to 102.3F. He was given
IV vanc/zosyn/azithro empirically there, which were then
discontinued on admission. Patient evaluation/management were as
per infectious disease recommendations. Because of the left
flank pain, he underwent CT A/P w/o contrast which showed no
acute abnormality. There was a question of
metallic density on right medial gluteal region, but on exam no
foreign material palpable or visualized, only excoriated skin
seen.
He had blood cultures and mycolytic BCx sent, NGTD on discharge.
He remained afebrile since admission. He did have on ___, a CTH
w/o contrast showing no acute abnormality, and CXR without
consolidation. Urinalysis was negative. Of note, he had a recent
___ positive L4 biopsy for MAC. He also had
repeat biopsy on ___ with bacterial stain/cx negative and
fungal NGTD. Other recent studies: galactomannan, BD glucan neg
___, EBV PCR 9588 on ___.
As for his hypoglycemia, it was 50 on fingerstick with EMS,
given oral glucose, and it rose to 69 in ED. Further glucose
FSBS were normal, and chem panel glucose were normal.
For his HIV/AIDS, his most recent CD4 prior to admit was ___ on ___. He was continued on atovaquone for PCP ___. He
was continued on ART, though patient reported being noncompliant
with them
since ___ recent discharge.
Dr. ___, patient's PCP and ID physician, was
notified by phone, and she stated she has an open door policy
with Mr. ___, and is more than happy to see him in follow up
on discharge. Patient was agreeable and looking forward to
visiting her office.
=================================
HOSPITAL SUMMARY BY PROBLEM LIST:
#Fever and left flank pain - in the ED, he had hypoglycemia and
fever to 102.3F. He was given IV vanc/zosyn/azithro empirically
there, which were then discontinued on admission.
-CT A/P w/o con showed no acute abnormality. Question
metallic density on right medial gluteal region, but on exam no
foreign material palpable or visualized today.
-appreciate ID input. Mycolytic BCx were sent. He was monitored
off abx. He has been afebrile since admission.
-___ CTH w/o con no acute abnl, CXR without consolidation
-BCx NGTD
-UA neg. RPR pending.
-of note he has recent ___ positive L4 biopsy for MAC. He had
repeat biopsy on ___ with bacterial stain/cx negative and
fungal NGTD.
-other recent studies: galactomannan, BD glucan neg ___, EBV PCR
9588 on ___
#hypoglycemia - resolved since admit.
#HIV/AIDS - CD4 ___ on ___. A repeat check of CD4
was 180 on ___.
-continue atovaquone for PCP ppx
-___ ID input, will continue ART. Patient reportedly
noncompliant with them
since ___ recent discharge.
-note past OI include disseminated MAC, PCP, ___.
#transaminitis
#chronic HCV infection (genotype 1a, 4 log10 VL on ___
#isolated HBcAb positive (___)
-no hyperbilirubinemia. LFT elevated back on ___, but improved
since on admission.
-when stabilized and has outpatient care established, further
workup/treatment indicated.
#G6PD deficiency - avoid certain drugs such as sulfa. Atovaquone
as above.
#anemia - normocytic 7.5 hgb on admit, improved on ___. LDH was
only 324. If suspect hemolysis related to G6PD deficiency, will
then check further labs. Tbili normal.
#reduced LVEF 45% on ___ TTE - echo report stated question of
PVC related cardiomyopathy. Will continue home lisinopril. He
could benefit from a beta blocker.
#polysubstance abuse (cocaine, IVDA, EtOH) - No need for CIWA.
Continue supportive care.
-appreciate SW consult input.
#HLD - continue atorvastatin compatible with ART
#R meningioma - stable on CTH this admission.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Atovaquone Suspension 1500 mg PO DAILY
3. Dolutegravir 50 mg PO DAILY
4. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
5. Sarna Lotion 1 Appl TP BID:PRN itch
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
9. Lisinopril 2.5 mg PO DAILY
10. Terbinafine 1% Cream 1 Appl TP BID
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Atovaquone Suspension 1500 mg PO DAILY
5. Dolutegravir 50 mg PO DAILY
6. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
7. Lisinopril 2.5 mg PO DAILY
8. Sarna Lotion 1 Appl TP BID:PRN itch
9. Terbinafine 1% Cream 1 Appl TP BID
Discharge Disposition:
Home
Discharge Diagnosis:
HIV/AIDS
Fever
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Instructions: Dear Mr. ___,
It was a pleasure to be a part of your care team at ___
___.
====================================
Why did you come to the hospital?
====================================
-You had fevers in our emergency department.
====================================
What happened at the hospital?
====================================
-You underwent blood tests and imaging tests of the belly which
did not show a point of new infection. You were monitored
closely for fevers, which did not recur.
==================================================
What needs to happen when you leave the hospital?
==================================================
-Please see Dr. ___, your primary care doctor. She
is very happy and looking forward to seeing you in her office!
As you know, she has an open door policy. Your official
appointment is 1:30 ___ on ___, but you may visit her today if
you are able to.
-Take your medications every day as directed by your doctors
-___ attend all of your doctor appointments, this is
especially important to help with your ongoing medical problems!
It was a pleasure taking care of you during your stay!
Sincerely,
Your ___ team
Followup Instructions:
___
|
10144359-DS-16 | 10,144,359 | 29,787,205 | DS | 16 | 2152-02-16 00:00:00 | 2152-02-16 17:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Fevers/Chills
Intoxication (opioid/alcohol)
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a background history of AIDS (most recent CD4 180 in
___, polysubstance abuse (IV heroin use, cocaine, EtOH),
chronic HCV infection, G6PD deficiency, bipolar disorder and
previously EF of 45%, who was brought in by ambulance after
being found slumped in a laundromat bathroom, with a hypodermic
needle on the adjacent floor.
Patient reports IV heroin use today, with cocaine use yesterday.
Sourced heroin from his usual distributor. Denies using a
'dirty' needle or licking the needle. He injected the heroin
directly into a vein. Denies loss of consciousness; states he
remembers going into the bathroom and everything post this up to
admission to ED. Of note, he reports smoking cocaine on ___,
but denies alcohol use. However, he does admit to consuming
'several' nips a
day usually.
On further questioning, patient says he has been experiencing
chronic lower back and bilateral foot pain. This is not a new
issue. He also has been experiencing right knee pain, but again
this is a chronic issue.
With regards to infective symptoms, patient does report several
days of nasal congestion, fevers, sore throat and diarrhea.
Diarrhea is watery in nature and has been experiencing three
episodes a day for three days. He has experienced these symptoms
in the past when withdrawing from heroin use. Denies neck
stiffness, headache, shortness of breath, cough, sputum
production, abdominal pain and lower urinary tract symptoms.
Recent ED visit two weeks ago, with negative infectious workup,
including biopsy of left thigh lesion, sputum culture, blood
culture and stool cultures.
In ED, initial VS were; Temp 99.1 HR 78 BP 118/76 RR 20 SaO2
97%RA
Labs were notable for a positive urine cocaine and opiate
screen, serum ethanol raised at 27, and few bacteria without
leukocytes/nitrites on urinalysis.
CT head showed no acute abnormality. Chest X-ray demonstrated no
acute definite acute intra-thoracic abnormality.
Received thiamine and acetaminophen in ED, before transferring
to the floor.
Vitals on transfer were; Temp 99.2 HR 65 BP 101/70 RR 23 SaO2
97%RA
Upon arrival to the floor, patient appeared to be agitated and
restless. Lying in bed, but noticeably uncomfortable, constantly
rolling and pulling at the sheets. He was minimally verbally
responsive, but repeated the above story. Furthermore, he agreed
his symptoms were likely reflective of previous episodes of
withdrawal. Of note, patient has not been taking his home
medications as he lost them, and has not followed up with a
doctor since discharge in ___.
Past Medical History:
1. HIV/AIDS (history of PCP pneumonia and disseminated ___
2. HCV genotype 1a
3. EBV viremia
4. HBV ___ core antibody positive)
5. Polysubstance abuse (cocaine, opioid, EtOH)
6. Bipolar disorder
7. Depression
8. G6PD deficiency
9. Gout
Social History:
___
Family History:
Mother and father both have history of cancer (unknown form).
Physical Exam:
===============================
ADMISSION PHYSICAL EXAMINATION:
===============================
VS: Temp 98.3 BP 157/97 HR 55 RR 18 SaO2 98% RA
GENERAL: lying in bed, visibly agitated and restless
HEENT: NT/AC, EOMI, PERRLA although dilated at baseline, mild
conjunctival pallor, anicteric sclera, oral mucosa dry, black
pigmented lesion on his tongue, small lesion on lower lip
NECK: supple, non-tender, no LAD, no JVD
CV: RRR, S1 and S2 normal, no murmurs/rubs/gallops
RESP: CTAB, no wheeze/crackles, breathing comfortably without
use of accessory muscles of respiration
___: soft, non-tender, not distended, BS normoactive
BACK: no spinal tenderness
EXTREMITIES: moving all four extremities with purpose, no
pitting edema, DP 2+ bilaterally
SKIN: multiple pigmented lesions with previous biopsy site of
one of these lesions healing
NEURO: CN II-XII intact, strength ___ in all extremities
===============================
DISCHARGE PHYSICAL EXAMINATION:
===============================
VS: Temp 98.5 BP 156/90 HR 62 RR 18 SaO2 100% RA
GENERAL: lying in bed, appears comfortable with no distress
HEENT: mild conjunctival pallor, anicteric sclera, MMM
NECK: supple, non-tender, no LAD, no JVD
CV: RRR, S1 and S2 normal, no murmurs/rubs/gallops
RESP: CTAB, no wheeze/crackles, breathing comfortably without
use of accessory muscles of respiration
___: soft, non-tender, not distended, BS normoactive
EXTREMITIES: moving all four extremities with purpose, no
pitting edema, DP 2+ bilaterally
SKIN: multiple pigmented lesions with previous biopsy site of
one of these lesions healing
NEURO: A/O x3, grossly intact
Pertinent Results:
===============
ADMISSION LABS:
===============
___ WBC-3.8* RBC-3.19* Hgb-8.2* Hct-27.2* MCV-85 MCH-25.7*
MCHC-30.1* RDW-16.3* RDWSD-50.4* Plt ___
___ Neuts-46.3 ___ Monos-14.1* Eos-2.7 Baso-0.5 Im
___ AbsNeut-1.74 AbsLymp-1.35 AbsMono-0.53 AbsEos-0.10
AbsBaso-0.02
___ Glucose-80 UreaN-11 Creat-0.9 Na-139 K-4.5 Cl-104
HCO3-22 AnGap-13
___ ASA-NEG Ethanol-27* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
___ URINE MUCOUS-RARE*
___ URINE HYALINE-1*
___ URINE RBC-2 WBC-1 BACTERIA-FEW* YEAST-NONE EPI-0
___ URINE BLOOD-NEG NITRITE-NEG PROTEIN-30* GLUCOSE-NEG
KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG
___ URINE COLOR-Yellow APPEAR-Clear SP ___
___ URINE bnzodzpn-NEG barbitrt-NEG opiates-POS*
cocaine-POS* amphetmn-NEG oxycodn-NEG mthdone-NEG
======
MICRO:
======
___ URINE
URINE CULTURE: NO GROWTH
___ BLOOD CULTURE
Blood Culture: NO GROWTH ON DATE OF DISCHARGE
___ Blood (CMV AB)
CMV IgG ANTIBODY: PND
CMV IgM ANTIBODY: PND
================
IMAGING/STUDIES:
================
___ CXR
No definite acute intrathoracic abnormality.
___ CT HEAD WITHOUT CONTRAST
No acute intracranial abnormality. Stable right occipital
extra-axial lesion compatible with meningioma.
===========
OTHER LABS:
===========
___ Parst S-NEGATIVE
___ WBC-6.4 Lymph-26 Abs ___ CD3%-77 Abs CD3-1285
CD4%-11 Abs CD4-184* CD8%-60 Abs CD8-996* CD4/CD8-0.18*
___ Ret Aut-1.1 Abs Ret-0.04
___ calTIBC-341 Ferritn-17* TRF-262
___ HBsAg-NEG HBsAb-NEG HBcAb-POS*
___ CRP-31.8*
___ HCV VL-PND
___ HIV1 VL-PND
___ SED RATE-25
___ EBV PCR, QUANTITATIVE, WHOLE BLOOD-PND
===============
DISCHARGE LABS:
===============
___ WBC-4.3 RBC-3.96* Hgb-9.9* Hct-33.4* MCV-84 MCH-25.0*
MCHC-29.6* RDW-15.9* RDWSD-49.2* Plt ___
___ Glucose-91 UreaN-8 Creat-0.8 Na-143 K-3.8 Cl-105
HCO3-23 AnGap-15
___ ALT-12 AST-27 AlkPhos-118 TotBili-0.4
___ Calcium-8.5 Phos-2.8 Mg-1.9
Brief Hospital Course:
Providers: ___ with a background history of AIDS (most recent
CD4 184 in ___, polysubstance abuse (IV heroin use, cocaine,
EtOH), chronic HCV infection, G6PD deficiency, bipolar disorder
and previously EF of 45%, who was brought in by ambulance after
being found slumped in a launderette bathroom, with a hypodermic
needle on the adjacent floor.
====================
ACTIVE/ACUTE ISSUES:
====================
# Fever
# AIDS (with CD4 184)
Patient BIBA after being found slumped over in a launderette
bathroom, following heroin/cocaine use. Endorsed a three day
history of fevers, nasal congestion, sore throat and watery
diarrhea (episodes x3 per day). Denies all other symptoms. In
ED, was found to have a low grade fever, with a temp max of
100.3F. Urinalysis with few bacteria, without
leukocytes/nitrites. CXR without acute cardiopulmonary process.
Extensive work-up of FUO over the course of two recent
admissions has been negative. Fevers possibly secondary to
transient bacteremia in setting of recurrent IVDU vs
hypersensitivity reactions to drugs or drug adulterants ("Cotton
fever"), which would explain why he has remained afebrile during
his multiple hospitalizations. No back pain, and recent
sub-optimal MRI of the spine at ___ without obvious abscess or
osteo (despite prior ___. Ddx includes disseminated ___ (given
epidemiology of FUO in immunocompromised AIDS patients, although
CT A/P ___ here at ___ and CT chest
___ without LAD), EBV viremia (CMV DNA neg earlier this
month), less likely stool parasites with CD4 at this level and
negative parasite stool studies at ___ 2 weeks ago (and absence
of diarrhea now). Chronic L foot pain with mildly elevated
inflammatory markers raises the possibility of smoldering
osteomyelitis. Low suspicion for PCP given absence of hypoxia
and clear CXR. Mr. ___ is adamant about leaving the hospital
today and is declining an X-ray of the L foot. It is reasonable
to discharge him, as he has remained afebrile without a
leukocytosis and with negative BCx to date. He is not sure where
he'll be staying, but he has given us the number of his niece
should any of his pending studies require action (BCx, EBV, CMV
antibodies, HCV VL). Social work has arranged for him to present
to ___ through ___ for establishment of care and facilitation
of methadone treatment. We have made an appointment for him with
his ID doctor and PCP, ___ at ___ for
___. We will provide him with prescriptions, including
for his ARVs, on discharge. I counseled him on the importance of
presenting for follow up and adhering to these medications.
# Polysubstance abuse and withdrawal
Patient has a long history of polysubstance abuse, including IV
heroin use, cocaine use and EtOH abuse. Reports using up to 1g
of heroin a day, with clean hypodermic needles. Endorses
previous episodes of withdrawal, with similar symptoms he was
experiencing on this occasion. Reported IV heroin use and
smoking cocaine one day prior to admission, and IV heroin use on
the day of admission. Denied EtOH use, although serum ethanol in
ED elevated at 27. Restless and agitated on admission. He was
managed with a CIWA scale (lorazepam 0.5mg PO Q4H:PRN for CIWA
>10) and ___ scale for withdrawal. Required minimal
intervention. Patient at baseline at time of discharge. Reviewed
by social work, willing to partake in methadone program.
Provided information regarding ___ clinic (through
___).
# HIV/AIDS
Patient has a background history of HIV/AIDs, for which he is
prescribed antiretroviral therapy. Has been non-compliant with
medication in the community. Most recent CD4 count prior to
admission was 180 in ___. Complicated by PCP pneumonia and
disseminated MAC in the past. ART therapy was restarted during
admission. CD4 count was 186. HIV viral load was pending on
discharge. Continued on atovaquone and acyclovir prophylaxis
while an inpatient, and discharged on his outpatient ARV regimen
and prophylaxis.
======================
CHRONIC/STABLE ISSUES:
======================
# G6PD deficiency
Diagnosis confirmed in the past. Care was taken to avoid
contraindicated drugs over the course of his admission.
# Anemia
This is likely a chronic issue. Hemoglobin was 8.2 on admission.
Likely component of iron deficiency given low ferritin.
Hemoglobin on discharge was 9.9. Iron repletion was deferred
given c/f occult infection but should be addressed as
outpatient.
# Reduced LVEF 45% (___)
Patient had reported EF of 45% on echocardiogram in ___. However, this was on a background of heavy PVC burden,
therefore the impression was one of PVC induced cardiomyopathy.
Repeat echocardiogram in ___ with EF of 65%. Continued on
lisinopril during admission.
# HLD
Continued atorvastatin.
# Right meningioma
Remained stable, with no interval changes on CT head on
admission.
====================
TRANSITIONAL ISSUES:
====================
- discharge WBC 4.3
- discharge Hgb 9.9
- discharge HIV CD4 186
- discharge HIV VL pending on discharge
MEDICATION CHANGES:
NONE
[] follow-up with PCP as arranged
[] recommend ___ clinic to be set up for methadone
program/follow-up visits
[] TO CONTACT PATIENT, CALL: ___, niece, number :
___
[] recommend X-ray of left foot for left foot pain in setting of
mildly elevated inflammatory markers, as patient unwilling to
have same while inpatient
[] further workup for FUO as appropriate in the outpatient
setting
[] Pending results on discharge include CMV/EBV, HCV viral load,
HIV viral load and final blood cultures. Follow-up in clinic.
[] Patient found to be persistently iron deficient, further
workup and management in the outpatient setting.
=======================================
CODE STATUS: Full, presumed
CONTACT: ___, brother/HCP, cell: ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Atovaquone Suspension 1500 mg PO DAILY
5. Dolutegravir 50 mg PO DAILY
6. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
7. Lisinopril 2.5 mg PO DAILY
8. Sarna Lotion 1 Appl TP BID:PRN itch
9. Terbinafine 1% Cream 1 Appl TP BID
10. ValACYclovir 1000 mg PO Q24H
11. QUEtiapine Fumarate 25 mg PO QHS
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth Once daily Disp #*30
Tablet Refills:*0
3. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth Once daily Disp #*30
Tablet Refills:*0
4. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone 750 mg/5 mL 10 ml by mouth Once daily Disp #*420
Milliliter Milliliter Refills:*0
5. Dolutegravir 50 mg PO DAILY
RX *dolutegravir [___] 50 mg 1 tablet(s) by mouth Once daily
Disp #*30 Tablet Refills:*0
6. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
RX *emtricitabine-tenofovir (TDF) [Truvada] 200 mg-300 mg 1
tablet(s) by mouth Once daily Disp #*30 Tablet Refills:*0
7. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth Once daily Disp #*30
Tablet Refills:*0
8. QUEtiapine Fumarate 25 mg PO QHS
RX *quetiapine 25 mg 1 tablet(s) by mouth Once daily Disp #*30
Tablet Refills:*0
9. Sarna Lotion 1 Appl TP BID:PRN itch
RX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % Apply to area
for itch Twice daily Refills:*0
10. ValACYclovir 1000 mg PO Q24H
RX *valacyclovir 1,000 mg 1 tablet(s) by mouth Once daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol/Opioid withdrawal
Low grade fever of unknown origin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
WHY YOU CAME TO THE HOSPITAL
You were brought in by ambulance to ___ after you were found
slumped over in a laundromat bathroom.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL
- You had a low grade fever of 100.3F with no further episodes
- We monitored you for symptoms of alcohol/heroin withdrawal
- You received some medication to ease the symptoms of
withdrawal
- Blood and urine tests did not reveal a cause for your episode
of fever
WHAT YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL
- It is important you keep taking your medications
- You need to follow-up with your PCP as we have arranged
- Recommend attending ___ clinic tomorrow to be
set-up with methadone program/follow-up appointments
It was a pleasure taking care of you.
Your ___ Healthcare Team
Followup Instructions:
___
|
10144359-DS-17 | 10,144,359 | 23,696,555 | DS | 17 | 2154-03-17 00:00:00 | 2154-03-20 00:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / Sulfa (Sulfonamide Antibiotics) / ibuprofen
Attending: ___.
Chief Complaint:
Epidural abscess/osteomyelitis
Major Surgical or Invasive Procedure:
L3-4 incision and drainage, laminectomy, and fusion (___)
L3-4 incision and drainage, laminectomy, and fusion-second stage
(___)
History of Present Illness:
Extracted from Admission History and Physical
___ hx of polysubstance abuse (IV heroin, coke, ETOH), HIV,
chronic HVC infection, G6PD deficiency, bipolar disorder here w
concern for substance use asking for treatment for a spinal
infection that was partially treated at ___.
Patient states he took IV heroin, cocaine and ETOH on day of
presentation.
In the ED, patient was overall well-appearing and resting
comfortably in bed upon initial assessment though acting
bizarrely and scratching his head and walking around his
stretcher without difficulty.
- In the ED, initial vitals were: 98.8 97 119/82 19 100% RA
- Exam was notable for:
Mental status intact. A&O ×3.
Motor and sensory function grossly intact in all 4 extremities.
Cranial nerve exam intact.
Extraocular motion normal. Primary disconjugate gaze. Pupils
equal and reactive to light bilaterally.
Able to ambulate without difficulty.
- Labs were notable for:
CBC: WBC 3.3, Hgb 9.9, Platelets 172
BMP: Wnl
Lactate: 0.8
- Studies were notable for: None
- The patient was given: Vanc/Cefepime and IVF
On arrival to the floor, patient was laying in bed comfortably.
He would only answer questions with yes/no. He was unable to
discuss his medical history, his medications, or elaborate about
his recent admission at ___ when he had his epidural abscess. He
did say that he is taking his medications as prescribes and that
the team should call ___ at ___ for them. He
believes that his HIV is under control. Has lumbar back pain,
but
denies fevers or chills."
Past Medical History:
-HIV/AIDS by virtue of PCP pneumonia and disseminated ___ in
___. -HCV Denotype 1a.
-EBV viremia.
-HBV core antibody positivity. ___ core antibody positive).
-Polysubstance abuse (heroin, cocaine, and alcohol).
-Bipolar disorder.
-G6PD deficiency.
-Depressive disorder.
-Gout.
Social History:
___
Family History:
Maternal and paternal histories of unspecified cancers.
Physical Exam:
ADMISSION EXAM
=============
VITALS: 98.4 125/73 66 18 97 Ra
GENERAL: Laying comfortable in bed.
HEENT: Eyes closed on exam
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. Soft
___
systolic murmur.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: Lumbar spine tenderness at L5
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: Warm, no edema, no splinter hemorrhages
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout.
DISCHARGE EXAM
==============
VITALS: T 98.5, HR 79, BP 103/64, RR 16, O2 100% RA
GENERAL: Well appearing thin male.
HEENT: Anicteric sclerae. Oropharynx clear.
NECK: No cervical lymphadenopathy.
CV: Regular rate and rhythm. S1/S2. No murmur.
PULMONARY: Comfortable. Lungs are clear.
ABDOMEN: Soft. Non-tender. No hepatosplenomegaly.
BACK: Lumbar surgical scar is healing well.
EXTREMITIES: No peripheral edema.
NEURO: Strength is full and sensation is grossly intact
throughout.
Pertinent Results:
ADMISSION LABS
=============
___ 10:56PM BLOOD WBC-3.3* RBC-3.44* Hgb-9.9* Hct-31.8*
MCV-92 MCH-28.8 MCHC-31.1* RDW-13.0 RDWSD-43.8 Plt ___
___ 10:56PM BLOOD Neuts-43.0 ___ Monos-18.1*
Eos-5.7 Baso-1.5* Im ___ AbsNeut-1.42* AbsLymp-1.03*
AbsMono-0.60 AbsEos-0.19 AbsBaso-0.05
___ 10:56PM BLOOD Glucose-85 UreaN-20 Creat-1.1 Na-136
K-4.5 Cl-102 HCO3-24 AnGap-10
___ 11:07PM BLOOD Lactate-0.8
DISCHARGE LABS
=============
___ 01:45PM BLOOD WBC-3.3* RBC-3.25* Hgb-9.3* Hct-29.6*
MCV-91 MCH-28.6 MCHC-31.4* RDW-13.2 RDWSD-44.3 Plt ___
___ 01:45PM BLOOD Neuts-51.7 ___ Monos-12.1 Eos-5.7
Baso-1.5* Im ___ AbsNeut-1.71 AbsLymp-0.92* AbsMono-0.40
AbsEos-0.19 AbsBaso-0.05
___ 04:42AM BLOOD UreaN-12 Creat-1.0
___ 01:45PM BLOOD CRP-8.4*
PERTINENT STUDIES
===============
MR ___ (___)
IMPRESSION:
1. Study is moderately degraded by motion. Additionally, please
note study is
limited due to lack of sagittal T1 and postcontrast imaging,
which was not
obtained due to patient inability to further tolerate
examination.
2. Allowing for difference in technique, grossly stable L3-4
level findings
concerning for discitis osteomyelitis, with probable psoas
muscle abscesses
above and below the L3-4 level as described.
3. L3-4 moderate to severe vertebral canal, mild right and
severe left neural
foraminal narrowing secondary to a epidural collection better
demonstrated on
2 months prior outside contrast lumbar spine MRI.
4. Additional multilevel lumbar spondylosis and epidural fat as
described.
5. Limited imaging of the kidneys demonstrate right at least
partially cystic
structure, incompletely characterized.
___ MR ___ SECOND READ (___)
IMPRESSION:
1. Second read request for a study performed and interpreted at
___.
2. Progressive diskitis and osteomyelitis at L3-L4 level, with
an increase in
the size of the prevertebral and epidural collections, and the
collection in
the superior aspect of L4 vertebral body.
3. Severe spinal canal stenosis at L3-L4 secondary to the
epidural
collection.
___ CT ABDOMEN/PELVIS SECOND READ (___)
1. Diskitis involving the L3-4 intervertebral disc space
associated with a
prevertebral abscess and an epidural abscess at this level, as
described in
detail above.
2. No abdominal or pelvic lymphadenopathy or solid organ
abnormality
identified.
3. Likely degenerative endplate changes seen at the
anterosuperior endplate of
the T12 vertebra.
LENIS (___)
IMPRESSION
No evidence of deep venous thrombosis in the right lower
extremity veins.
Brief Hospital Course:
___ immunocompromised male by virtue of HIV/AIDS,
disseminated ___ in ___, ___ osteomyelitis in ___,
recrudescence of this earlier this year, treatment fragmented
and interrupted by complex psychosocial circumstances, presents
seeking care for the same. He underwent L3-4 incision and
drainage, laminectomy, and fusion and completed a six-week
course of antibiotics.
___ epidural abscess/osteomyelitis. He has a long complex
history of disseminated in ___, followed by ___ osteomyelitis
in ___, and a recrudescence of this in early ___. His
treatment was fragmented and interrupted by complex psychosocial
circumstances. He returned to ___ in ___ where an MRI
demonstrated interval evolution of L3-4 epidural abscess,
osteomyelitis, and diskitis. Mycobacterium was recovered from a
second percutaneous sampling but surgical management was
deferred in favor of antibiotics alone. The isolate was
submitted to a reference laboratory for confirmation and
susceptibilities. He was discharged from ___ for behavioral
dysregulation before the completion of antibiotic therapy. He
underwent two-step L3-4 incision drainage, laminectomy, and
fusion on ___. His postoperative course was
complicated by recurrent fevers but he eventually defervesced.
Surgical specimens were positive for the same. He was a treated
with a six-week course amikacin, azithromycin, rifampin, and
ethambutol ___ to ___. CRP dropped
dramatically by the completion of treatment. His renal function
was unadulterated. He was discharged to the care of his
primary/infectious diseases provider at ___.
#HIV/AIDS. CD4 113 which is in keeping with his CD4 in ___ of
this year. Viral load is detectable but suppressed. His
compliance with HAART is unreliable. Dolutegravir and Truvada
were continued. Atovaquone prophylaxis was added.
#Polysubstance abuse. He relapsed after his discharge from
___. Opioid analgesia in the immediate post-operative period
was converted to his usual dose of Suboxone. MAT is coordinated
by the ___ at ___.
#Cardiomyopathy. Borderline left ventricular ejection fraction
in ___ was attributed to heavy PVC burden. This recovered by
___. He had no peripheral fluid retention or features of low
output. It is not clear if he takes ___ medical
therapy in any form.
#Leukopenia/chronic normocytic anemia. Likely multifactorial in
the form ___ epidural abscess/osteomyeltitis on a background
of HIV and HCV. Stable in the 3-range and 9-range, respectively.
#Asymmetric sensorineural hearing loss (R>L). Hearing impairment
predated use of aminoglycoside. A repeat audiology exam is
warranted in three months.
#Bipolar disorder. Continued quetiapine.
#G6PD deficiency. Atovaquone in that regard.
TRANSITIONAL ISSUES:
=================
[ ] Repeat CD4 count and amend prophylaxis accordingly. He was
discharged with atovaquone as pneumocystis prophylaxis.
[ ] Orthopedics-spine follow-up two weeks after discharge.
[ ] Recommend Quantiferon and coccidioides serology.
[ ] Audiology referral for asymmetric hearing loss.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Atovaquone Suspension 1500 mg PO DAILY
5. Dolutegravir 50 mg PO DAILY
6. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
7. Lisinopril 5 mg PO DAILY
8. Sarna Lotion 1 Appl TP BID:PRN itch
9. ValACYclovir 1000 mg PO Q24H
10. QUEtiapine Fumarate 50 mg PO QHS
11. Azithromycin 500 mg PO 3X/WEEK (___)
12. Bictegrav-Emtricit-Tenofov Ala 1 TAB PO DAILY
13. Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL DAILY
14. Vitamin D ___ UNIT PO 1X/WEEK (MO)
15. Gabapentin 1200 mg PO TID
16. Ethambutol HCl 20 mg/kg PO 3X/WEEK (___)
Discharge Medications:
1. Dolutegravir 50 mg PO BID
RX *dolutegravir [Tivicay] 50 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
2. Gabapentin 600 mg PO TID
RX *gabapentin 600 mg 1 capsule(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
3. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
4. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone 750 mg/5 mL 10 ml by mouth once a day Refills:*0
7. Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL DAILY
Consider prescribing naloxone at discharge
8. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
RX *emtricitabine-tenofovir (TDF) [Truvada] 200 mg-300 mg 1
tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0
9. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
10. QUEtiapine Fumarate 50 mg PO QHS
RX *quetiapine 50 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
11. Sarna Lotion 1 Appl TP BID:PRN itch
12. ValACYclovir 1000 mg PO Q24H
RX *valacyclovir [Valtrex] 1,000 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
13. Vitamin D ___ UNIT PO 1X/WEEK (MO)
RX *ergocalciferol (vitamin D2) [Vitamin D2] 50,000 unit 1
capsule(s) by mouth once a week Disp #*8 Capsule Refills:*0
14. HELD- Bictegrav-Emtricit-Tenofov Ala 1 TAB PO DAILY This
medication was held. Do not restart Bictegrav-Emtricit-Tenofov
Ala until your PCP tells you to restart.
Discharge Disposition:
Home
Facility:
___
Discharge Diagnosis:
PRIMARY
-___ epidural abscess/osteomyelitis
SECONDARY
-HIV/AIDS
-Polysubstance abuse
-Postoperative fever
-Leukopenia
-Normocytic anemia
-Bipolar disorder
-G6PD deficiency
-Asymmetric sensorineural hearing loss
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 hospitalized for an infection of your
spine with an uncommon bacteria called mycobacterium
avium-intracellulare (___). You had a spine surgery. You were
then treated with four antibiotics for six weeks. Please remain
in contact with your primary care provider. Seek care if you
have a fever, severe back pain, or weakness in your legs. We
wish you all the best.
Sincerely,
Your ___ care team
Followup Instructions:
___
|
10144406-DS-17 | 10,144,406 | 29,118,181 | DS | 17 | 2149-11-09 00:00:00 | 2149-11-10 21:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: Laparoscopic cholecystectomy converted to open.
History of Present Illness:
___ year old ___ speaking male with h/o obesity, HTN,
HLD, GERD and recent TURP ___ for symptomatic BPH presents
with 5 days of RUQ abdominal pain without relief. History
obtained with the help of a ___ interpreter over the
phone. Pain much worse today than it had been the previous
days, and worse after eating a meal of rice and beans.
Describes it as a "poking" sensation, worse with movement.
Denies n/v/d. Has had constipation. No fevers/chills, chest
discomfort, or SOB. +occasional palpitations. Increased burping
and flatus. Denies ever having had pain like this before,
however, notes from PCP indicate that he had been complaining of
RLQ pain in ___. Had prior RUQ US x 2 that showed
gallstones, but no e/o acute inflammation at that time ___,
___. Seen by GI for constipation, treating for IBS
(constipation predominant) with stool softeners. Today's shows
mainly sludge, normal CBD, and distended gallbladder. Underwent
EGD and colonoscopy in ___ with a few adenomatous polyps, no
e/o malignancy, EGD with mild gastritis.
Past Medical History:
HYPERTENSION
OVERWEIGHT
URINARY FREQUENCY
ABNORMAL EKG
CHOLESTEROL
HYPERGLYCEMIA
ABNORMAL LIVER FUNCTION TESTS
ANEMIA
ABDOMINAL PAIN
DEPRESSION
INSOMNIA
Surgical History updated, no known surgical history.
Social History:
___
Family History:
Comments: no fh cancer, no colon or prostate ca.
Relative Status Age Problem Comments
Mother ___ ___ DIABETES TYPE II
CORONARY ARTERY
DISEASE
HYPERTENSION
Father Living DIABETES TYPE II
HEART DISEASE
Brother 8 BROTHERS
Daughter Living ___ DEPRESSION
Son Living ___ WELL
Son Living ___
Physical Exam:
On admission:
Vitals: pain ___ 103ST 157/75 17 98%RA
GEN: A&O x3, obese, grumpy, but cooperative, male, burping
frequently, no emesis
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, protuberant, tender RUQ with ___ and voluntary
guarding, no rebound tenderness, normoactive bowel sounds, no
palpable masses
Ext: No ___ edema, ___ warm and well perfused
At discharge:
GEN: A&O x3, obese, cooperative
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, nontender, surgical staples in place RUQ, no
evidence of wound dehiscence or skin erythema, appropriately
tender overlying incision, JP drain in place R flank draining
serosanguinous fluid
serosang, +BS, no rebound/guarding
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 08:41PM BLOOD Lactate-1.6
___ 08:25PM BLOOD Albumin-4.4
___ 04:25AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.5
___ 05:20AM BLOOD Calcium-8.5 Phos-2.5* Mg-3.3*
___ 07:55PM BLOOD Mg-2.7*
___ 06:20AM BLOOD Calcium-8.0* Phos-2.4* Mg-2.8*
___ 09:30AM BLOOD Albumin-2.9*
___ 05:10AM BLOOD Calcium-8.1* Phos-2.5* Mg-2.6
___ 06:10AM BLOOD Calcium-7.8* Phos-2.3* Mg-2.4
___ 05:35AM BLOOD Calcium-8.0* Phos-2.6* Mg-2.1
___ 05:25AM BLOOD Calcium-7.9* Phos-2.4* Mg-1.8
___ 05:20AM BLOOD Calcium-7.8* Phos-3.7 Mg-2.0
___ 05:45AM BLOOD Calcium-7.8* Phos-3.4 Mg-1.8
___ 08:25PM BLOOD cTropnT-<0.01
___ 04:25AM BLOOD cTropnT-<0.01
___ 08:25PM BLOOD Lipase-74*
___ 04:25AM BLOOD Lipase-43
___ 05:20AM BLOOD Lipase-82*
___ 09:30AM BLOOD Lipase-85*
___ 06:10AM BLOOD Lipase-440*
___ 05:35AM BLOOD Lipase-533*
___ 05:25AM BLOOD Lipase-942*
___ 05:20AM BLOOD Lipase-1231*
___ 05:45AM BLOOD Lipase-1177*
___ 08:25PM BLOOD ALT-71* AST-64* AlkPhos-212* TotBili-1.1
___ 04:25AM BLOOD ALT-85* AST-79* AlkPhos-214* TotBili-2.0*
DirBili-1.4* IndBili-0.6
___ 05:20AM BLOOD ALT-112* AST-88* AlkPhos-305*
TotBili-3.9*
___ 09:30AM BLOOD ALT-145* AST-185* LD(LDH)-362*
AlkPhos-366* TotBili-4.1*
___ 05:10AM BLOOD ALT-182* AST-263* AlkPhos-545*
TotBili-4.4* DirBili-3.5* IndBili-0.9
___ 06:10AM BLOOD ALT-197* AST-241* AlkPhos-642*
TotBili-2.8* DirBili-2.1* IndBili-0.7
___ 05:35AM BLOOD ALT-149* AST-122* AlkPhos-567*
TotBili-1.7*
___ 05:25AM BLOOD ALT-110* AST-68* AlkPhos-511* TotBili-1.3
___ 05:45AM BLOOD ALT-76* AST-47* AlkPhos-395* TotBili-0.9
___ 08:25PM BLOOD Glucose-161* UreaN-10 Creat-0.7 Na-134
K-3.8 Cl-94* HCO3-23 AnGap-21*
___ 04:25AM BLOOD Glucose-193* UreaN-9 Creat-0.7 Na-137
K-3.9 Cl-95* HCO3-28 AnGap-18
___ 05:20AM BLOOD Glucose-166* UreaN-13 Creat-0.9 Na-138
K-3.7 Cl-96 HCO3-29 AnGap-17
___ 07:55PM BLOOD Na-139 K-3.5 Cl-98
___ 06:20AM BLOOD Glucose-149* UreaN-20 Creat-1.4* Na-139
K-3.9 Cl-101 HCO3-27 AnGap-15
___ 05:10AM BLOOD Glucose-148* UreaN-19 Creat-1.1 Na-141
K-3.8 Cl-102 HCO3-28 AnGap-15
___ 06:10AM BLOOD Glucose-120* UreaN-22* Creat-0.9 Na-146*
K-3.6 Cl-106 HCO3-28 AnGap-16
___ 05:35AM BLOOD Glucose-143* UreaN-22* Creat-1.0 Na-141
K-3.2* Cl-103 HCO3-29 AnGap-12
___ 05:25AM BLOOD Glucose-143* UreaN-16 Creat-1.0 Na-137
K-3.3 Cl-100 HCO3-24 AnGap-16
___ 05:20AM BLOOD Glucose-146* UreaN-17 Creat-1.0 Na-137
K-3.4 Cl-102 HCO3-24 AnGap-14
___ 05:45AM BLOOD Glucose-139* UreaN-17 Creat-1.1 Na-134
K-3.5 Cl-97 HCO3-24 AnGap-17
___ 08:25PM BLOOD Plt ___
___ 04:25AM BLOOD ___
___ 04:25AM BLOOD Plt ___
___ 05:20AM BLOOD Plt ___
___ 05:15PM BLOOD Plt ___
___ 09:30AM BLOOD ___ PTT-27.7 ___
___ 05:10AM BLOOD Plt ___
___ 06:10AM BLOOD Plt ___
___ 05:35AM BLOOD ___
___ 05:35AM BLOOD Plt ___
___ 05:25AM BLOOD ___
___ 05:25AM BLOOD Plt ___
___ 05:20AM BLOOD Plt ___
___ 05:45AM BLOOD Plt ___
___ 08:25PM BLOOD Neuts-82.5* Lymphs-8.4* Monos-8.1
Eos-0.3* Baso-0.2 Im ___ AbsNeut-15.29*# AbsLymp-1.56
AbsMono-1.50* AbsEos-0.05 AbsBaso-0.04
___ 08:25PM BLOOD WBC-18.5*# RBC-4.58* Hgb-12.6* Hct-37.7*
MCV-82 MCH-27.5 MCHC-33.4 RDW-13.2 RDWSD-39.5 Plt ___
___ 04:25AM BLOOD WBC-19.7* RBC-4.22* Hgb-11.7* Hct-35.2*
MCV-83 MCH-27.7 MCHC-33.2 RDW-13.3 RDWSD-40.2 Plt ___
___ 05:20AM BLOOD WBC-19.8* RBC-3.96* Hgb-10.8* Hct-33.5*
MCV-85 MCH-27.3 MCHC-32.2 RDW-13.9 RDWSD-43.2 Plt ___
___ 05:15PM BLOOD WBC-20.1* RBC-3.39* Hgb-9.3* Hct-28.7*
MCV-85 MCH-27.4 MCHC-32.4 RDW-14.2 RDWSD-43.8 Plt ___
___ 07:55PM BLOOD Hct-28.8*
___ 06:20AM BLOOD Hct-27.7*
___ 05:10AM BLOOD WBC-12.6* RBC-3.30* Hgb-9.0* Hct-28.2*
MCV-86 MCH-27.3 MCHC-31.9* RDW-14.9 RDWSD-46.5* Plt ___
___ 06:10AM BLOOD WBC-12.8* RBC-3.27* Hgb-8.7* Hct-26.8*
MCV-82 MCH-26.6 MCHC-32.5 RDW-14.6 RDWSD-43.5 Plt ___
___ 05:35AM BLOOD WBC-13.3* RBC-3.20* Hgb-8.6* Hct-26.4*
MCV-83 MCH-26.9 MCHC-32.6 RDW-14.5 RDWSD-43.4 Plt ___
___ 05:25AM BLOOD WBC-11.8* RBC-2.98* Hgb-8.1* Hct-24.0*
MCV-81* MCH-27.2 MCHC-33.8 RDW-14.4 RDWSD-41.8 Plt ___
___ 05:20AM BLOOD WBC-12.1* RBC-2.90* Hgb-7.8* Hct-23.8*
MCV-82 MCH-26.9 MCHC-32.8 RDW-14.6 RDWSD-42.5 Plt ___
___ 05:45AM BLOOD WBC-12.8* RBC-2.88* Hgb-7.8* Hct-23.7*
MCV-82 MCH-27.1 MCHC-32.9 RDW-14.7 RDWSD-42.5 Plt ___
___ 12:00AM URINE Mucous-RARE
___ 12:00AM URINE RBC->182* WBC-68* Bacteri-NONE Yeast-NONE
Epi-<1
___ 12:00AM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 12:00AM URINE Color-Yellow Appear-Hazy Sp ___
___ 05:15PM ASCITES ___ Misc-LIPASE = 4
___ 04:39PM ASCITES TotBili-3.4
___ 8:25 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:00 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
___ Abdominal US:
1. Findings concerning for acute cholecystitis.
2. Echogenic liver may be due to fatty deposition. Please note
more advanced forms of liver disease cannot be excluded on the
basis of this appearance.
___ CT abdomen and pelvis w contrast:
1. Status post open cholecystectomy with postsurgical changes.
No acute abdominal abnormality.
2. Bibasilar atelectasis and small bilateral pleural effusions.
Small right subpulmonic fluid. Consider superimposed infection
in the right lung base in the appropriate clinical settings.
___ MRCP:
IMPRESSION:
There is artifact from difficulty in breath hold and oral
contrast limiting the evaluation.
Postsurgical changes from recent cholecystectomy. No
choledocholithiasis. No biliary or pancreatic duct dilation.
No drainable fluid collection.
No imaging evidence of acute pancreatitis. Possible mild
chronic
pancreatitis.
Right lower lobe disease more has the appearance of atelectasis
than
pneumonia. Small left pleural effusion.
9 mm left adrenal nodule, too small to characterize
definitively, but
unchanged in size since ___, most likely representing an
adenoma. Endocrine lab correlation may be obtained.
Brief Hospital Course:
The patient presented to ___ Emergency Department and was
evaluated by the ___ service for abdominal pain on ___. Pt
was evaluated by anaesthesia on ___. Given findings, the
patient was taken to the operating room for lap converted to
open cholecystectomy on ___. Please see the operative note
for details. Pt was extubated, taken to the PACU until stable,
then transferred to the ward for observation.
___ JP amylase 70, GI c/s for elevated lipase ->
recommended no need to trend lipase, discharged home.
___ lipase up, CT abd/pelvis ordered
___ advanced to and tolerating regular diet, + BM, K
repleted, downtrending T bili
___ HTN SBP 170-180-> started Hydralazine 10mg q6H
___ received 5 mg vit K, jp sent for bilirubin, ducc supp.
+flatus
___ sent for full labs, tbili. Blood tinged NGT-> started
IV pantoprazole
___ on dPCA, standing tylenol
___ OR. electrolytes repleted
___ voluntary guarding, ___. ERCP normal.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with IV and PCA and
then transitioned to oral medication 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 with a
___ tube in place for decompression. The NG tube was
then removed, and therefore, the 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.
HEME: The patient's blood counts were closely watched for signs
of bleeding.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Finasteride 5 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Tamsulosin 0.4 mg PO QHS
8. diclofenac sodium 1 % topical QID
9. melatonin 5 mg oral QPM
10. Sildenafil 100 mg ORAL DAILY:PRN prior to sexual activity
11. Acetaminophen 650 mg PO TID
12. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
13. Phenazopyridine 100 mg PO TID
Discharge Medications:
1. Single point cane
Dx: Open cholecystectomy
Px: Good
Duration: 13 (thirteen) months
2. Acetaminophen 650 mg PO Q6H:PRN Pain
3. Amlodipine 10 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Finasteride 5 mg PO DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
9. Tamsulosin 0.4 mg PO QHS
10. Milk of Magnesia 30 mL PO Q6H:PRN Constipation
11. Senna 8.6 mg PO BID:PRN Constipation
12. Aspirin 81 mg PO DAILY
13. diclofenac sodium 1 % topical QID
14. melatonin 5 mg oral QPM
15. Phenazopyridine 100 mg PO TID
16. Sildenafil 100 mg ORAL DAILY:PRN prior to sexual activity
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:
Dear Mr. ___,
You presented to the ___ on
___ and were found to have acute cholecystitis, an
inflammation of your gallbladder. You were admitted to the
Acute Care Surgery team for further medical management.
You were taken to the Operating Room and had a laparoscopic
converted to open cholecystectomy and had your gallbladder
removed. You were started on antibiotics to help treat and
prevent abdominal infection and will be discharged with a course
of oral antibiotics.
You are now tolerating a regular diet and your pain is better
controlled. You have worked with Physical Therapy who
recommends your discharge to home with visiting nurse services
to evaluate your abdominal drain and surgical wounds. You are
now medically cleared for discharge. Please note the following
discharge instructions:
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Your incisions may be slightly red around the staples. This is
normal. Your staples will be removed at your follow-up
appointment in the Acute Care Surgery clinic.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10144424-DS-23 | 10,144,424 | 26,254,341 | DS | 23 | 2176-11-27 00:00:00 | 2176-11-28 13:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / atenolol / Colchicine
Attending: ___.
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
___ - Upper endoscopy
History of Present Illness:
___ with advanced dementia, h/o hematemesis, h/o treated H.
pylori and GERD who presents from his SNF with hematemesis. He
was recently admitted from ___ for hematemesis. At that
time, the family refused endoscopy and a clear source of upper
GI bleeding was not identified. He spent some time in the ICU
for E. coli sepsis, which improved with cefepime and then
ceftriaxone, which he finished a course of after discharge to
his SNF.
In the ED, initial VS: T 99.0 HR 104 BP 101/63 RR 26 SpO2 96%.
An NG tube was placed and revealed 200cc of coffee ground
emesis, the patient subsequently self d/c'd NG tube and was not
replaced. He received CTX 1g and Flagyl 500mg IV in the ED. UA
was notable for >182 WBCs, positive nitrites and 82 RBCs in the
setting of a chronic Foley. ED noted large amount of urine
output after Foley replaced. He also received 2L NS. Guaiac
negative.
Currently, he has no complaints and appears comfortable, only
answering with single word respondes. No further hematemesis
since arrival to the floor.
Past Medical History:
- Advanced Dementia
- GERD/stricture, esophagus dilated ___
- UGI bleed and gastric distention-hospitalized ___ NG tube,
H. pylori treated with Prilosec, Flagyl, and Biaxin, ___
___.
- Thickening of the anorectal area noted on CAT scan ___-
sigmoidoscopy
- Gallstones
- BPH
- Urinary retention with a chronic Foley as of ___.
- Depression
- HTN
- HLD
- Gout
Social History:
___
Family History:
Unable to obtain from patient, by report: 2 healthy children
without significant medical problems.
Physical Exam:
Admission exam:
VS - Temp 100.9 F, BP 96/72, HR 66, R 16
GENERAL - appears cmfortable, non-verbal but responds to name
___ - dry MM, dried blood/emesis around lips
NECK - supple, no JVD
LUNGS - CTA bilat, no r/rh/wh, poor effort, resp unlabored, no
accessory muscle use
HEART - PMI non-displaced, irregular HR, nl rate, no MRG, nl
S1-S2
ABDOMEN - +BS, soft/ND, some grimacing with palpation of RUQ, no
masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e
SKIN - no rashes or lesions
NEURO - arousable to voice, moves all extremities in response to
painful stimuli, non-cooperative with full neuro exam but PERRLA
and moving all extremities. Cogwheeling present on exam along
with some resting tremor, predominantly in UEs
Discharge exam - unchanged from above, except as below:
LUNGS - Scattered expiratory wheezing
ABDOMEN - +BS, soft/NT/ND
NEURO - awake and alert, A&Ox1, appropriate and following
commands
Pertinent Results:
Admission labs:
___ 12:50PM BLOOD WBC-18.3*# RBC-3.93*# Hgb-13.5*#
Hct-41.2# MCV-105* MCH-34.4* MCHC-32.8 RDW-13.8 Plt ___
___ 12:50PM BLOOD ___ PTT-25.7 ___
___ 12:50PM BLOOD Glucose-143* UreaN-30* Creat-1.4* Na-142
K-4.1 Cl-103 HCO3-27 AnGap-16
___ 12:50PM BLOOD ALT-11 AST-21 AlkPhos-86 TotBili-0.8
___:50PM BLOOD Albumin-3.8 Calcium-9.5 Phos-3.7 Mg-1.9
___ 01:44PM BLOOD Lactate-3.0*
___ 01:45PM URINE RBC-28* WBC->182* Bacteri-MANY Yeast-NONE
Epi-<1
___ 01:45PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 01:45PM URINE Color-Yellow Appear-Cloudy Sp ___
Hct trend:
___ 12:50PM BLOOD WBC-18.3*# RBC-3.93*# Hgb-13.5*#
Hct-41.2# MCV-105* MCH-34.4* MCHC-32.8 RDW-13.8 Plt ___
___ 10:45PM BLOOD WBC-14.0* RBC-3.39* Hgb-11.8* Hct-35.8*
MCV-105* MCH-34.8* MCHC-33.0 RDW-13.9 Plt ___
___ 08:40AM BLOOD WBC-12.2* RBC-3.02* Hgb-10.4* Hct-32.1*
MCV-106* MCH-34.6* MCHC-32.5 RDW-13.9 Plt ___
___ 12:45PM BLOOD WBC-11.0 RBC-2.81* Hgb-10.0* Hct-29.7*
MCV-106* MCH-35.6* MCHC-33.8 RDW-13.9 Plt ___
___ 09:45PM BLOOD WBC-13.2* RBC-3.09* Hgb-10.9* Hct-32.8*
MCV-106* MCH-35.2* MCHC-33.2 RDW-13.7 Plt ___
___ 07:10AM BLOOD WBC-11.7* RBC-2.85* Hgb-10.0* Hct-30.1*
MCV-106* MCH-35.1* MCHC-33.2 RDW-13.5 Plt ___
___ 08:05AM BLOOD WBC-11.2* RBC-2.94* Hgb-10.4* Hct-30.8*
MCV-105* MCH-35.3* MCHC-33.7 RDW-13.6 Plt ___
___ 07:05AM BLOOD WBC-6.5 RBC-3.11* Hgb-10.7* Hct-32.2*
MCV-104* MCH-34.4* MCHC-33.2 RDW-13.7 Plt ___
___ 07:47AM BLOOD WBC-4.4 RBC-2.77* Hgb-9.6* Hct-28.8*
MCV-104* MCH-34.6* MCHC-33.4 RDW-13.5 Plt ___
___ 11:00AM BLOOD WBC-5.4 RBC-2.73* Hgb-9.5* Hct-28.5*
MCV-104* MCH-34.7* MCHC-33.3 RDW-13.6 Plt ___
Discharge labs:
___ 11:00AM BLOOD WBC-5.4 RBC-2.73* Hgb-9.5* Hct-28.5*
MCV-104* MCH-34.7* MCHC-33.3 RDW-13.6 Plt ___
___ 07:47AM BLOOD Glucose-82 UreaN-10 Creat-0.7 Na-143
K-4.0 Cl-107 HCO3-29 AnGap-11
Imaging:
-CXR (___): No acute cardiac or pulmonary process.
-CT abd/pelvis (___):
1. Findings suggestive of urinary outlet obstruction with
bilateral
hydroureteronephrosis and urothelial hyperemia concerning for
cystitis and ureteritis or other infectious process, in this
patient with positive
urinalysis and elevated serum WBC with possible acute on chronic
process. Suggest urology consultation. Foley catheter balloon
inflated within the penile urethra. Repositioning/removal and
repositioning so that it is within the bladder recommended.
2. Stomach distended with fluid without finding to suggest
mechanical
obstrucion.
3. Possible mild proctitis, similar in appearance to prior
studies from
___.
-Renal US (___): No hydronephrosis.
-EGD (___): Small hiatal hernia
Pylorus was tight, but no ulcer seen.
The bulb is foreshortened, no ulcer
Polyps in the stomach body and fundus
No blood, food, liquid in stomach.
Otherwise normal EGD to third part of the duodenum
Recommendations: The findings do not account for the blood
-UGIS (___):
1. Presbyesophagus with patulous esophagus with holdup of
contrast. The
patient is at risk of aspiration.
2. The remainder of the study is normal. Findings were
discussed by phone with the referring physician on pager number
___ at 4:14 p.m.
-TTE (___): Left ventricular wall thickness, cavity size,
and global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets are
mildly thickened (?#).
IMPRESSION: Very suboptimal image quality. No discrete
vegetation or pathologic flow seen on technically very
suboptimal study.
Brief Hospital Course:
___ with advanced dementia, GERD, h/o treated H. pylori and
recent E. coli sepsis who presents with hematemesis and is found
to have a UTI.
#Coffee ground emesis/UGI bleed: He was reported to have coffee
ground emesis at his nursing home, consistent with his prior
episodes. In the ED, NG tube was placed which reportedly
returned 200cc of coffee ground emesis before patient pulled the
tube. There was some question whether the NG output was purely
coffee grounds or if there was a component of feculent material.
He was guaiac negative with brown stool. He was started on an
IV PPI and gastroenterology was consulted. His Hct was
monitored q8h initially, and trended down with IV hydration, he
appeared very hemoconcetrated at admission. After discussion
with the patient's daughter and GI, the decision was made to
perform an EGD to evaluate for source of bleeding. The EGD was
essentially normal with no source identified, however a tight
pylorus was identified. An upper GI series was performed which
showed no obstruction, only a dilated esophagus consistent with
age and his past history of treated esophageal stricture. He
did not have any further episodes of vomiting and his Hct
remained stable compared to his prior baseline in our records.
He was discharged back to his rehab facility. He did not
receive any blood transfusions during this admission. Mr.
___ will follow-up with GI as an outpatient.
#Gastric distention: CT scan in the ED noted gastric distention
on CT abdomen and there was concern for feculent NG output.
Clinically, his abdominal exam was benign with no distention and
only minimal tenderness to palpation. He did not have any
vomiting during this admission and an NG tube was not replaced.
There was no pyloric obstruction on EGD, although the pylorus
was noted to be tight. As noted above, UGIS showed no
obstruction.
#MSSA Bacteremia - ___ bottles of initial blood cultures were
positive for Coag(+) staph. He was started on vancomycin
empirically on ___, all other bottles remained negative and
subsequent BCx were also negative. A TTE was performed to
evaluate for endocarditis which was a poor quality study
secondary to patient habitus and poor cooperation, but showed no
vegetations and no valvular flow abnormalities. ID was
consulted who recommended cefazolin for 4 weeks (he has a PCN
allergy but tolerated cephalosporins in the past), which he will
complete at his SNF via midline. He has 22 additional days of
abx after discharge for bacteremia with inability to rule out
endocarditis.
#UTI/hydronephrosis: UCx grew E. coli which was resistant only
to Cipro, which is consistent with his prior urine cultures. He
was started on ceftriaxone during this admission and will be
discharged on cefazolin as above. On his initial CT abd/pelvis,
he was noted to have bladder distention with bilateral
hydronephrosis. His foley catheter was replaced in the ED and a
large amount of urine was noted to come out after this. A
repeat renal US the second day of admission showed resolution of
hydronephrosis, Foley continued to drain well.
___: Cr elevated to 1.4 at admission, trended down to 0.7 at
discharge, which is his baseline. Elevation may have been from
obstruction given hydronephrosis noted on initial CT. He also
appeared somewhat volume depleted on exam and had been vomiting
with hemoconcetration noted on labs, indicating that he was
likely pre-renal as well. He was kept on maintenance fluids
while NPO for EGD and while taking poor PO. At discharge, his
PO intake improved.
#Tachycardia: He had some brief episodes of tachycardia which
self-resolved. During these, he remained asymptomatic with no
drop in blood pressure or O2 sat. EKG was poor quality but
appeared consistent with atrial fibrillation. Each episode
resolved on it's own without intervention and he remained
predomonantly in sinus rhythm with frequent PACs.
#Advanced dementia: Patient's baseline not entirely clear,
nursing home reports that he is able to ask for food or to use
the bathroom and his case manager thought he looke dmore sleepy
this admission. At discharge, he will be continued on his home
dose of Namenda. He appeared to have some Parkinsonian features
on exam (cogwheeling, masked face and resting tremor) and this
may be playing a role in his dementia.
#GERD and h/o H. pylori: Received 14 days of triple therapy in
the past. He was placed on an IV PPI during this admission. At
discharge, he will continue his home dose of omeprazole.
#HTN: He remained normotensive during this admission with
systolic BP in the 100-140 range. At admission, he was not on
any antihypertensives.
#Depression: Continued his home doses of mirtazapine and
citalopram.
#Gout: No hot or swollen joints. Continued on home dose of
allopurinol.
#Code status this admission: DNR/DNI
#Transitional issues:
-Will follow-up with GI as an outpatient regarding his ongoing
episodes of hematesis
-Had some brief episodes on telemetry concening for atrial
fibrillation during this admission, should be monitored for this
in the future
-Will continue cefazolin 2g q12h for 22 days after discharge for
his MSSA bacteremia
-Midline should be removed after antibiotic course is complete
on ___
-Please check weekly CBC/diff, Chem-7 and LFTs while on
antibiotics and fax results to ___
Medications on Admission:
-omeprazole 20mg PO daily
-allopurinol ___ PO daily
-bisacodyl 10mg PO daily
-citalopram 20mg PO daily
-MVI 1 tab PO daily
-vitamin D3 800IU PO daily
-divalproex ___ PO bid
-docusate 100mg PO bid
-namenda 10mg PO bid
-mirtazapine 15mg PO daily
-senna 17.2mg PO qHS
-tamsulosin 0.8mg PO qHS
-Tylenol PRN
-Bisacodyl supp PRN
-Trazodone 25mg PO qHS PRN insomnia
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
2. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
6. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: Two (2)
Capsule, Ext Release 24 hr PO HS (at bedtime).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever or pain.
9. divalproex ___ mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO every twelve (12) hours.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. senna 8.6 mg Tablet Sig: Two (2) Tablet PO twice a day as
needed for constipation.
12. memantine 10 mg Tablet Sig: One (1) Tablet PO twice a day.
13. trazodone 50 mg Tablet Sig: Half Tablet PO at bedtime as
needed for insomnia.
14. cefazolin 1 gram Recon Soln Sig: Two (2) grams Intravenous
every twelve (12) hours for 22 days: Last dose on ___. Please
remove midline after last dose of antibiotics.
15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for wheezing or dyspnea.
16. bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal
once a day as needed for constipation.
17. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day.
18. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: Midline
can be removed after antibiotic course is complete on ___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Hematemesis
Bacteremia
Secondary diagnoses:
Advanced dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your admission to
___ for vomiting blood. You were seen by the
gastroenterologists who performed an upper endoscopy. No source
of bleeding was found during this procedure. Your blood counts
remained similar to your prior values and you will be discharged
back to your nursing home.
You were also found to have a UTI and blocked Foley catheter at
admission. We replaced your Foley and started you on
antibiotics for the UTI.
One of your blood culture results returned positive and there
was no obvious evidence of infection on your heart valves. You
will receive antibiotics via the midline that we placed for 8
days after discharge. Your midline can be removed after the 8
day course of antibiotics is completed. If you have any fevers,
chills or lethargy at your nursing home you should return to
___.
The following changes were made to your medications:
START cefazolin 2g via midline for 22 days (last dose on ___
START albuterol 1 nebulizer every ___ hours as needed for SOB or
wheezing
Followup Instructions:
___
|
10144859-DS-5 | 10,144,859 | 21,500,757 | DS | 5 | 2129-12-14 00:00:00 | 2129-12-15 18:13:00 |
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:
Pelvic pain
Major Surgical or Invasive Procedure:
Repair of vaginal cuff dehiscence
History of Present Illness:
___ G5P5 with h/o HIV s/p TLH, BS in ___ for fibroids
presented with sudden onset pain o/n at 2am. She reported she
awoke at 2am with sudden onset severe abdominal pain. Had
episode of emesis at the time of pain. Had some light spotting
with urination when using the bathroom, not certain if it is
from
vagina or urine. Last BM 2 days ago, +constipation. +chills.
Denied dysuria, fevers, heavy vaginal bleeding, abnormal vaginal
discharge.
Past Medical History:
PObHx: G5P5
- SVD x5
PGynHx:
- Last Pap: ___
- Denies h/o abnormal Paps
- H/o chlamydia, denies other STIs
PMHx:
- HIV
PSHx:
- H/o biopsy of buttock mass
- TLH, BS
- Excisional biopsy of breast
Social History:
___
Family History:
Non-contributory
Physical Exam:
General: NAD, in some discomfort
CV: RRR
Lungs: CTAB
Abdomen: soft, non-distended, tender in epigastric region
GU: pad with no spotting
Extremities: no edema, no TTP, pneumoboots at bedside
Pertinent Results:
___ 11:35AM BLOOD WBC-5.0 RBC-3.76* Hgb-11.0* Hct-33.3*
MCV-89 MCH-29.3 MCHC-33.0 RDW-14.7 RDWSD-47.8* Plt ___
___ 11:35AM BLOOD Neuts-72.1* ___ Monos-5.4 Eos-1.4
Baso-0.4 Im ___ AbsNeut-3.59 AbsLymp-1.01* AbsMono-0.27
AbsEos-0.07 AbsBaso-0.02
___ 11:35AM BLOOD Plt ___
___ 11:35AM BLOOD Glucose-87 UreaN-8 Creat-0.8 Na-140 K-3.6
Cl-104 HCO3-28 AnGap-8
___ 08:15AM BLOOD ALT-21 AST-48* AlkPhos-123* TotBili-0.6
___ 11:35AM BLOOD Calcium-8.3* Phos-2.2* Mg-2.0
___ 07:09PM BLOOD Lactate-2.8*
CT ___
IMPRESSION:
1. Large amount of free intraperitoneal air with a dominant
pocket of free air seen in the deep pelvis. While the source is
not definitively identified, it is most likely pelvic in origin.
2. Calcifications noted along the gallbladder fundal wall could
reflect early porcelain gallbladder. Outpatient followup with
general surgery could be considered.
Brief Hospital Course:
Ms. ___ was admitted to GYN after repair of her vaginal cuff
dehiscence. Please see operative report for more details.
Her pain was controlled with oral Tylenol, ibuprofen, oxycodone
and IV dilaudid for breakthrough. For antibiotic coverage, she
received Zosyn (___) and was transitioned to PO Augmentin
on ___ for a planned 14-day course total. Pelvic fluid Gram
stain with showed no PMNs or organisms. Her lactate was 2.8 at
admission and remained that level on recheck.
She was continued on her home HIV medications.
On postoperative day 2, she was voiding, ambulating, tolerating
a regular diet, was afebrile, and her pain was controlled on
oral pain medications. She was discharged home with oral
augmentin and follow-up.
Medications on Admission:
darunavir 800 mg daily; ritonavir 100 mg daily; truvada 1 tab
daily
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
Do not take more than 4000mg in 24 hours
RX *acetaminophen 500 mg ___ tablet(s) by mouth q6h prn Disp
#*60 Tablet Refills:*0
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
Take the entire course of antibiotics
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth
twice a day Disp #*24 Tablet Refills:*0
3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
Take with food
RX *ibuprofen 600 mg 1 tablet(s) by mouth q6h prn Disp #*60
Tablet Refills:*0
4. Ondansetron ODT 4 mg PO ONCE Duration: 1 Dose
Do not take more than 8 mg in 8 hours
RX *ondansetron 4 mg ___ tablet(s) by mouth q8h prn Disp #*10
Tablet Refills:*0
5. Darunavir 800 mg PO DAILY
6. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
7. RiTONAvir 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Vaginal cuff dehiscence
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the gynecology service after your
procedure. You have recovered well and the team believes you are
ready to be discharged home. Please call Dr. ___ office with
any questions or concerns. Please follow the instructions below.
General instructions:
** Nothing in the vagina (no tampons, no douching, no sex) for
3 (THREE) months.
** Take the full course of antibiotics prescribed (Augmentin)
for 12 days
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Take a stool softener such as colace while taking narcotics
to prevent constipation.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your post-op appointment.
* No heavy lifting of objects >10 lbs for 6 weeks.
* You may eat a regular diet.
* You may walk up and down stairs.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
10144972-DS-19 | 10,144,972 | 22,630,457 | DS | 19 | 2185-12-31 00:00:00 | 2185-12-31 20:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
amoxicillin / shellfish derived
Attending: ___.
Chief Complaint:
abdominal and chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization ___
History of Present Illness:
Mr. ___ is a ___ man with history of tobacco use,
DMII, HTN, HLD, 3vCAD s/p NSTEMI s/p DES to LCx and OM1, asthma
presenting with chest pain.
The patient reports that he was in his usual state of health. He
ate a large meal on the evening before admission of meatballs
and
donuts. This morning, he awoke around ___ with crampy, lower
abdominal pain and the urge to defecate but he could not. He
then
developed mid-epigastric/central substernal chest tightness,
nonexertional, nonradiating, associated with shortness of
breath,
nausea, and diaphoresis. He then had an episodes of NBNB emesis.
He denies any fevers or chills. He reports that his abdominal
discomfort felt identical to his prior heart attack (he had
predominantly abdominal not chest pain) so he presented to the
ED
for further evaluation.
He further tells me that over the past year he has had
progressively more frequent exertional chest pain. He reports
that beginning a few months ago, he began to notice chest pain
and dizziness when he climbed a flight of stairs. He now notices
chest pain and dizziness nearly daily with exertion that is
relieved by rest.
Initial vitals: 3 98.3 75 132/73 16 98% RA
Exam notable for: Not documented
Labs notable for: CBC wnl, INR 0.8; LFTs wnl, lipase 281; BUN/Cr
___ trop <0.01 x2; lactate 1.0; ___ 257
Imaging notable for:
- RUQUS:
1. Cholelithiasis without other findings of acute cholecystitis.
2. Echogenic liver consistent with steatosis. Other forms of
liver disease including steatohepatitis, hepatic fibrosis, or
cirrhosis cannot be excluded on the basis of this examination.
- CXR: No acute intrathoracic process.
- EKG: NSR, LAD, NI, submm STE in I, AVL (consistent with
prior),
no acute ischemic changes
Consults: Cardiology:
While pancreatitis is likely to be driving his presentation, the
fact that his presenting symptoms are the same as his prior ACS
needs to be interrogated. Since he is chest pain free, biomarker
negative thus far, and has no ischemic ECG changes.
Recommendations
- No heparin GTT for now given he is chest pain free and
biomarker negative thus far.
- Admit to medicine for workup and treatment of his pancreatitis
- If his second troponin is positive or develops recurrent chest
pain, please call cardiology fellow for retriage
- Continue home ASA and statin
Patient was given:
___ 11:37 IV Ondansetron 4 mg
___ 11:37 IVF NS ( 1000 mL ordered)
___ 13:03 IVF LR
___ 13:03 IV Famotidine
___ 13:03 IV Morphine Sulfate 4 mg
___ 14:36 IVF LR 1000 mL
___ 14:36 IV Famotidine 20 mg
___ 19:17 IVF LR Started 350 mL/hr
___ 19:17 IV Morphine Sulfate 2 mg
___ 19:17 IV Ondansetron 4 mg
Vitals on transfer: 3 97.7 64 144/81 14 99% RA
On arrival to the floor, the patient reports that he feels
better. Denies chest pain, palpitations, shortness of breath,
abdominal pain, nausea at present.
Past Medical History:
- CAD with NSTEMI ___
-- Cardiac cath showed triple vessel disease with 60% mid,
diffuse 80% distal LAD lesions; 90% stenosis in the mid
xircumflex, 80% stenosis in the ___ Marginal, OM2 with 80%
stenosis s/p DES to mid LCx and OM1.
- DMII
- HTN
- HLD
- Tobacco use
- Asthma
- Erectile dysfunction
- Chronic back pain
Social History:
___
Family History:
Per OMR and confirmed with patient:
Father: ___ in ___ due to MI
Sister: unspecified heart murmur, DM
MGM: MI, DM
Physical Exam:
ADMISSION EXAM
VITALS: 98.4 154/89 71 18 97 ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Moist mucous membranes
CV: Heart regular, no murmur No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, mildly tender to palpation in
the midepigastrium. Bowel sounds present.
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: Dry skin on finger and forearms
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: Pleasant, appropriate affect
DISCHARGE EXAM
VS: ___ 0755 Temp: 98.5 PO BP: 148/68 HR: 65 RR: 18 O2 sat:
98% O2 delivery: RA
Gen - sitting up in bed, comfortable appearing
Eyes - EOMI, anicteric
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft nontender, normal bowel sounds, no rebound/guarding;
negative murphys sign
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3, moving all extremities
Psych - appropriate
Pertinent Results:
ADMISSION
___ 11:01AM BLOOD WBC-4.3 RBC-4.85 Hgb-13.8 Hct-40.5 MCV-84
MCH-28.5 MCHC-34.1 RDW-12.5 RDWSD-37.8 Plt ___
___ 11:01AM BLOOD Glucose-354* UreaN-22* Creat-0.9 Na-136
K-4.4 Cl-101 HCO3-19* AnGap-16
___ 11:01AM BLOOD ALT-20 AST-18 AlkPhos-63 TotBili-0.4
___ 11:01AM BLOOD Lipase-281*
___ 07:05AM BLOOD %HbA1c-14.1* eAG-358*
___ 11:01AM BLOOD Triglyc-257*
DISCHARGE
___ 07:15AM BLOOD WBC-4.9 RBC-4.61 Hgb-13.2* Hct-38.5*
MCV-84 MCH-28.6 MCHC-34.3 RDW-12.2 RDWSD-37.2 Plt ___
___ 07:35AM BLOOD Glucose-204* UreaN-15 Creat-0.9 Na-142
K-4.2 Cl-103 HCO3-27 AnGap-12
REPORTS
Cardiac cath ___
Stable 3 vessel disease with no changed from prior
Nuclear stress ___
IMPRESSION : No anginal symptoms or ischemic EKG chages to the
achieved
workload. Fair functional capacity. Nuclear report sent
separately.
IMPRESSION:
1. Reversible, medium sized, moderate severity perfusion defect
involving the RCA territory.
2. Normal left ventricular cavity size and systolic function.
RUQUS ___. Cholelithiasis without other findings of acute cholecystitis.
2. Echogenic liver consistent with steatosis. Other forms of
liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot
be excluded on the basis of this examination.
Brief Hospital Course:
This is a ___ year old male with past medical history of diabetes
type 2, hypertension, hyperlipidemia, CAD s/p remote DES
admitted ___ with epigastric pain, initially ruled out for
ACS, then found to have acute pancreatitis, thought to be of
gallstone etiology, treated conservatively with clinical
improvement, also found to have very poorly controlled diabetes
(A1c 14%), patient declining additional management of diabetes
and opting to leave against medical advice before surgical
referral for discussion re: cholecystectomy could be arranged
# Generalized abdominal pain secondary to acute pancreatitis,
suspected gallstone
Patient presented with epigastric pain, with initial labs
notable for lipase 281 (>3x upper limit of normal) without
additional LFT abnormalities. He denied alcohol. Triglycerides
were ~250. Right upper quadrant ultrasound showed
cholelithiasis without choledocholithiasis. Patient initially
worked up for cardiac cause of his pain, as below. On admission
to medicine, patient suspected to have acute pancreatitis.
Given clinical picture, etiology thought to be idiopathic versus
missed gallstone pancreatitis. Patient treated conservatively
with IV fluids, NPO, symptom management, and then was able to
advance diet to regular. Given concern for possible gallstone
etiology, he was recommended for surgical evaluation for
discussion re: risk/benefit and timing of cholecystectomy. He
declined this as an inpatient. Could consider outpatient
referral.
# CAD
Patient with history of prior drug eluting stent placement, who
presented with epigastric pain as above. Stress was concerning
for a reversible defect in RCA territory. Cardiac
catheterization on ___ showed stable 3-vessel disease unchanged
from prior catheterization. Continued ASA, Plavix, statin,
metoprolol. Recommended to follow-up as outpatient with ___
cardiology.
# Diabetes type 2 complicated by hyperglycemia
Patient previously on insulin, but per his report he
self-discontinued it due to inconvenience and several episodes
of symptomatic hypoglycemia. On admission he was found to have
A1c 14%. In setting of his acute pancreatitis and NPO status,
he was maintained on sliding scale. Once his pancreatitis
resolved patient was not willing to stay in the hospital to
allow for safe determination of an insulin plan. He was able to
verbalize understanding of relevant risks of leaving including
hyperglycemia and life threatening conditions. He left against
medical advice. Restarted metformin at discharge (48 hours
after cardiac catheterization) and recommended rapid follow-up
with PCP ___ (patient was not willing to stay
inpatient to allow for an attempt to arrange ___ follow-up
prior to his discharge). Patient reported he would call ___ and
___ regarding expedited follow-up
appointments on ___.
# Hypertension:
Held lisinopril initially, then restarted at discharge
# Abnormal Ultrasound Liver
Incidnetally showed "Echogenic liver consistent with steatosis.
Other forms of liver disease including steatohepatitis, hepatic
fibrosis, or cirrhosis cannot be excluded on the basis of this
examination." Could consider outpatient hepatology referral
Transitional issues
- Discharged home against medical advice
- Etiology of pancreatitis thought to be gallstone related;
would consider outpatient surgical referral for discussion of
risk/benefit of cholecystecomy
- Had cardiac catheterization this admission showing "stable
coronary disease involving all 3 vessels. No change since prior
angiogram." with recommendation for "Secondary prevention of
CAD"
- A1c 14%; patient reported previous issues with insulin
compliance, as well as several episodes of severe hypoglycemia
while on insulin; he left against medical advice before a safe
diabetes plan could be identified;
- Consider outpatient hepatology referral as above
- Contacted ___ via email regarding urgent transitional issues
above
> 30 minutes spent on this discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. MetFORMIN (Glucophage) 500 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Lisinopril 5 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Lisinopril 5 mg PO DAILY
5. MetFORMIN (Glucophage) 500 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
# Generalized Abdominal pain secondary to Acute pancreatitis
# Diabetes type 2 complicated by hyperglycemia
# CAD
# Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___:
It was a pleasure caring for you at ___. You were admitted
with abdominal pain and chest tightness.
While there was initial concern that this could be due to your
heart disease, the results of our testing indicated that it was
more likely the result of inflammation in your pancreas
("pancreatitis").
We suspect that this may have been caused by gallstones.
You were treated with IV fluids and pain medications.
We recommended that you be evaluated by a surgeon to discuss
having your gallbladder removed. We also noted that your
diabetes was very poorly controlled. We recommended that you
stay in the hospital to come up with a safe diabetes treatment
plan, or that you allow us to work out a rapid diabetes
follow-up plan for you. You did not wish to wait, and were able
to demonstrate understanding of the risks of leaving the
hospital including recurrent pancreatitis, high sugars, or other
life-threatening complications. You opted to leave the hospital
against our advice.
While recovering from you pancreatitis we recommend eating a low
fat diet and avoiding all alcohol.
Followup Instructions:
___
|
10144972-DS-20 | 10,144,972 | 20,914,059 | DS | 20 | 2186-08-01 00:00:00 | 2186-08-01 18:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
amoxicillin / shellfish derived / latex gloves
Attending: ___.
Chief Complaint:
nausea, vomiting, epigastric pain
Major Surgical or Invasive Procedure:
Cardiac cath with DES placed in mid RCA on ___
History of Present Illness:
Mr. ___ is a ___ man with history of tobacco use,
IDDM, HTN, HLD, 3vCAD s/p NSTEMI s/p DES to LCx and OM1 with 90%
LAD occlusion, asthma, gallstone pancreatitis s/p CCY presenting
with acute-on-chronic nausea, hyperemesis and epigastric pain.
Mr. ___ reports a history of chronic vomiting, ___ every
other morning, sometimes ___ per day, that began following
his
lap CCY. The vomit is always clear or yellow-colored, NBNB, and
not associated with fatty meals. He also reports non-radiating
epigastric pain that waxes and wanes and is usually associated
with N/V, but not always. He sometimes induces vomiting which
produces ___ minute relief of his epigastric pain. Palliating
factors include hot showers and ondansetron. Endorses marijuana
use in the evenings, including ___ before this recent
episode of hyperemesis. Denies recent fevers or chills,
diarrhea, alcohol use, polyuria, polydipsia. Had 3 formed
stools
today which is more than his typically regular daily BM. He has
difficulty with PO intake during these vomiting episodes and
poor
appetite but nonetheless has not lost weight in the past few
months.
Mr. ___ reports exacerbation of these symptoms in the past
day, with worsening epigastric pain, nausea and >10x episodes of
vomiting. Of note, the angina equivalent sx he experienced with
his MI in ___ were shoulder pain, diaphoresis, nausea and
epigastric pain that he reports is similar to his pancreatitis
pain. He endorses two recent episodes of transient SOB a/w IV
contrast administered for CT imaging here and at ___,
but
otherwise denies dyspnea, CP or palpitations.
Of note, the patient just presented to ___ ___ ___
with
complaint of unilateral headache and received a CTA head which
was normal. He reports 1.5 months of unilateral, pulsatile
headaches that begin behind his L eye, spread across his L
maxillary sinus area and radiate across the top of his head, a/w
an "ice-pick" sensation behind his eye. Feels an itching-like
sensation across his eye and maxillary sinus area as a prodrome
to these headaches. A/w photophobia, phonophobia, partially
relieved by Excedrin, no visual aura. These headaches began
after an incident of minor head trauma in which he inadvertently
struck himself in the face. He reports occasional pain a/w a L
molar and has not seen a dentist recently.
Lastly, he also endorses a skin rash for the past month on his
palms and shins. Notes that multiple bullae cyclically appear,
then become a flaky, pruritic, painful rash. Notes that this
rash began when he started working at Stop & ___ and handling
frequent produce covered in pesticides, though he typically
wears
gloves. Has handled mangoes and endorses a latex allergy. Had
a
similar rash occasionally in the past when he worked in ___ and wore gloves daily for work. Has not had a
recurrence of this rash since switching to the ___ department.
Past Medical History:
- CAD with NSTEMI ___
-- Cardiac cath showed triple vessel disease with 60% mid,
diffuse 80% distal LAD lesions; 90% stenosis in the mid
xircumflex, 80% stenosis in the ___ Marginal, OM2 with 80%
stenosis s/p DES to mid LCx and OM1.
- DMII
- HTN
- HLD
- Tobacco use
- Asthma
- Erectile dysfunction
- Chronic back pain
Social History:
___
Family History:
Per OMR and confirmed with patient:
Father: ___ in ___ due to MI
Sister: unspecified heart murmur, DM
MGM: MI, DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
VITALS: T98.1, HR88, BP176/105, RR16, O2Sat97% RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
No palpable cervical, supraclavicular, or axillary LAD, no oral
mucosal lesions, no exudate or abscess visible near L molar.
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 bowel sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill less than 2s. Hyperpigmented lesions on
shins, elbows and palms at sites of prior rash, no peripheral
edema. Lesions on palms are not painful.
NEUROLOGIC: AAOx3, CN2-12 intact. Grossly normal strength and
sensation.
DISCHARGE PHYSICAL EXAM:
==========================
Temp: AF PO BP: 130s-150s/7s-80s L Lying HR: 80 RR: 18 O2
sat: 98% O2 delivery: Ra
GENERAL: overweight man resting in bed in NAD, appears
comfortable
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes/crackles.
No
increased work of breathing.
ABDOMEN: soft, nontender/nondistended, no HSM
EXTREMITIES: warm, no edema
NEUROLOGIC: AAOx4, CN2-12 grossly intact with no focal neuro
deficits
Pertinent Results:
ADMISSION LABS:
=================
___ 06:15AM BLOOD WBC-8.2 RBC-4.60 Hgb-13.3* Hct-39.7*
MCV-86 MCH-28.9 MCHC-33.5 RDW-13.6 RDWSD-42.2 Plt ___
___ 06:15AM BLOOD Neuts-90.3* Lymphs-7.9* Monos-0.8*
Eos-0.0* Baso-0.4 Im ___ AbsNeut-7.44* AbsLymp-0.65*
AbsMono-0.07* AbsEos-0.00* AbsBaso-0.03
___ 06:15AM BLOOD ___ PTT-26.1 ___
___ 06:15AM BLOOD Glucose-240* UreaN-20 Creat-0.9 Na-140
K-4.8 Cl-106 HCO3-17* AnGap-17
___ 06:15AM BLOOD ALT-20 AST-33 AlkPhos-57 TotBili-0.6
___ 06:15AM BLOOD cTropnT-<0.01
___ 07:20PM BLOOD CK-MB-15* MB Indx-4.4 cTropnT-0.12*
___ 07:05AM BLOOD CK-MB-9 cTropnT-0.17*
___ 12:30PM BLOOD CK-MB-7 cTropnT-0.10*
___ 06:15AM BLOOD Albumin-4.2 Calcium-9.1 Phos-1.8* Mg-1.5*
___ 07:05AM BLOOD %HbA1c-7.4* eAG-166*
___ 07:20PM BLOOD Triglyc-119
___ 07:20PM BLOOD CRP-1.3
___ 06:53AM BLOOD pO2-76* pCO2-23* pH-7.50* calTCO2-19*
Base XS--2 Comment-GREEN TOP
___ 06:53AM BLOOD Lactate-3.2* Creat-0.9 K-4.5
DISCHARGE LABS:
==================
IMAGING:
============
CTA ABDOMEN ___:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
There is no evidence of focal lesions. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The
gallbladder is surgically absent.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of focal lesions or pancreatic ductal
dilatation. There is no peripancreatic stranding.
IMPRESSION:
1. No evidence of pulmonary emboli no acute aortic syndrome.
2. No CT evidence of pancreatitis or other acute intra-abdominal
process.
TTE ___:
---------------
The left atrial volume index is mildly increased. There is mild
symmetric left ventricular hypertrophy with a normal cavity
size. There is normal regional and global left ventricular
systolic function. Quantitative biplane left ventricular
ejection fraction is 60 %. Left ventricular cardiac index is
normal (>2.5 L/min/m2). There is no resting left ventricular
outflow tract gradient.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global biventricular systolic
function. Mild mitral regurgitation with normal valve
morphology.
Compared with the prior TTE (images reviewed) of ___ ,
regional/global left ventricular systolic function is now
improved.
CARDIAC CATH ___:
Coronary Description
The coronary circulation is right dominant.
LM: The Left Main, arising from the left cusp, is a large
caliber vessel. This vessel bifurcates into the
Left Anterior Descending and Left Circumflex systems.
LAD: The Left Anterior Descending artery, which arises from the
LM, is a large caliber vessel.
The Diagonal, arising from the proximal segment, is a medium
caliber vessel.
Cx: The Circumflex artery, which arises from the LM, is a large
caliber vessel. There is a 70% stenosis
in the proximal and mid segments. There is a ___ in the mid
segment. There is a 70% stenosis in the
distal segment.
The ___ Obtuse Marginal, arising from the proximal segment, is a
medium caliber vessel. There is a ___
in the proximal segment.
The ___ Obtuse Marginal, arising from the mid segment, is a
medium caliber vessel. There is an 80%
stenosis in the proximal segment.
RCA: The Right Coronary Artery, arising from the right cusp, is
a large caliber vessel. There is a 100%
stenosis in the proximal segment. There is a 60% stenosis in the
distal segment. There is a 60% stenosis
in the distal segment.
The Right Posterolateral Artery, arising from the distal
segment, is a medium caliber vessel. There is a
60% stenosis in the mid segment. Collaterals from the mid
segment of the ___ OM connect to the
proximal segment. Collaterals from the distal segment of the LAD
connect to the proximal segment.
The Right Posterior Descending Artery, arising from the distal
segment, is a medium caliber vessel.
Brief Hospital Course:
Mr. ___ is a ___ man with history of coronary artery
disease ___ presented atypically with NSTEMI, turned down for
CABG for poor LAD target, now s/p stenting of LCx and OM,
unrevascularized 60-80% LAD disease), diabetes, tobacco use,
hypertension, hyperlipidemia, idiopathic vs. gallstone
pancreatitis ___ (repeat coronary angiogram at that time was
unchanged) s/p elective CCY ___ who presented with
acute-on-chronic nausea, hyperemesis and epigastric pain, found
to have NSTEMI.
It was initially unclear if his NSTEMI was secondary to a
primary coronary artery thrombosis leading to atypical angina in
the form of upper GI symptoms vs. a primary upper GI process
leading to increased myocardial demand from severe hypertension
that was occurring in the setting of his epigastric pain,
nausea, and vomiting against a background of known
unrevascularized coronary artery disease.
He ultimately underwent diagnostic angiogram which revealed an
acute occlusion of the mid RCA for which he underwent ___
placement. After reperfusion many of his GI symptoms resolved
and/or greatly improved.
He was seen by the gastroenterology team prior to the
reperfusion who did not feel like his pain was consistent with
acute pancreatitis, but he should continue his evaluation as an
outpatient where he was scheduled to have a barium swallow and
EGD to evaluate for other conditions such as esophagitis or
peptic ulcer disease.
We ultimately discharged him to home after increasing his
lisinopril and starting a PPI. He was already taking DAPT given
his prior history of coronary stenting.
======================
TRANSITIONAL ISSUES
======================
[] Patient advised to see a dentist for evaluation of broken L
molar when he leaves the hospital.
[] Pt has had weeks of nausea/vomiting and was scheduled to
undergo GI workup with GI emptying study + endoscopy; after RCA
occlusion identified, it is believed his n/v was a chest pain
equivalent. - ___ not need further GI workup if symptoms improve
after stenting.
[] Increased Lisinopril to 10mg QDaily, please titrate as needed
[] Will need to be on DAPT with ASA + Plavix for likely ___ years
(to be determined by outpatient cardiologist).
[] Appears that patient had complete occlusion of RCA and
presented with symptoms of nausea/vomiting, but without CP.
Should be noted for future that GI symptoms are anginal
equivalent for him.
[] Had heartburn as inpatient, started on low dose PPI for 4
week trial. Please re-eval after this time or before if
heartburn not improved.
===============================
PROBLEM-BASED SUMMARY
===============================
#NSTEMI
#Mid RCA occlusion s/p ___
Initially concerning for either type 1 or type 2 MI I/s/o
intense stomach pain/n/v. Has unrevascularized CAD in the LAD,
but EKG was not suggestive of involvement of this territory. He
was very hypertensive and in considerable abdominal pain. He
underwent TTE ___ which was not revealing of any wall motion
abnormality and showed EF 60%, Mild symmetric LVH with normal
cavity size and regional/global biventricular systolic function.
Mild mitral regurgitation with normal valve morphology. Compared
with
the prior TTE (images reviewed) of ___ , regional/global
left ventricular systolic function is now improved. Blood
pressures were aggressively controlled with nitro drip, which
was weaned and PO imdur/lisinopril restarted. He was continued
on aspirin, Plavix, high dose statin, as well as heparin drip.
He underwent cardiac cath ___ which revealed a complete
occlusion of mid RCA that appeared to be weeks-old in nature.
Given sub-acute chronicity, had DES placed. His n/v/abdominal
pain improved after this, and it was thought that his GI
symptoms were an anginal equivalent given RCA distribution of
equivalent.
#Nausea/Vomiting/Emesis
Presentatin with n/v/epigastric pain as well as lipase of 200
initially concerning for recurrent pancreatitis, however CT scan
did not show any evidence of pancreatic inflammation. When he
was
admitted in ___ with pancreatitis, he did not have a CT scan
and was ruled in based on symptoms and lipase elevation alone.
GI was consulted who did not believe presentation was consistent
with pancreatitis, and original plan was for pt to undergo
workup with endoscopy after cath. He was managed with
anti-emetics and morphine PRN and diet was advanced as
tolerated. After cath revealed complete occlusion of mid RCA,
his abdominal symptoms were believed to be due to inferior
cardiac ischemia. His symptoms resolved after cath. If he
continues to have these symptoms as an outpatient, ACS should be
ruled out but patient should undergo further GI workup with
endoscopy.
#Hypertension
Patient admitted with BPs elevated to the 190s systolic, likely
I/s/o pain and n/v. Focus on nausea and pain control as
described above. His home lisinopril was held in the event that
pt will under cath ___. His metoprolol was increased to 12.5
Q6. He was started on a nitro gtt with good response and
eventually
weaned to home PO imdur. Lisinopril was uptitrated to 10mg on
discharge.
#DMII: Last A1c: 8.9% in ___, repeat A1C this admission
7.4%. He currently takes metformin and insulin 20U degludec QHS.
Did not fill Jardiance as his insurance does not cover it.
Managed inpatient with 10 units glargine and ISS, metformin
held.
#HA
#Broken L upper molar w/o e/o infection
Hx of 1.5mo of unilateral L-sided headaches a/w ice-pick-like
sensation, pulsatile radiation across the top of the head,
photophobia and phonophobia iso painful fractured L upper molar.
Migraine-like symptomatology, possibly odontogenic trigger.
Pain controlled with Tylenol PRN. Pt advised to see dentist
for evaluation of broken L molar after discharge.
#Contact dermatitis
Pt reports recent rashes on palms, elbows and shins that begin
as
pruritic, painful vesicles/bullae leading to peeling and
resolving to hyperpigented lesions. Noted significant worsening
of rashes with exposure to produce including mangoes, hx of
latex
allergy. No subsequent episodes since avoiding occupational
exposure, most likely contact dermatitis. Avoid occupational
exposure
to mangoes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO BID
4. Atorvastatin 80 mg PO QPM
5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. degludec 20 Units Bedtime
Discharge Medications:
1. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. degludec 20 Units Bedtime
3. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Clopidogrel 75 mg PO DAILY
8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
9. MetFORMIN (Glucophage) 500 mg PO BID
10. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
==========
Non ST elevation myocardial infarction
Nausea/vomiting/abdominal pain
Hypertension
Secondary:
===========
CAD with NSTEMI ___ s/p DES to mid LCx and OM1, with ongoing
60-80% LAD occlusion
Type II Diabetes Mellitus
Hyperlipidemia
Tobacco use
Asthma
Erectile dysfunction
Chronic back pain
Cholecystectomy ___ for ___ pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you had
nausea/vomiting and upper abdominal pain.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- We diagnosed you with a heart attack and you had a ___
placed in a blocked artery to restore blood flow to the heart
muscle. After the ___ was placed many of your symptoms
improved.
- You were seen by the gastroenterologists who did not feel like
you have pancreatitis, but should continue to have the
outpatient work up as scheduled to see if there are any issues
with the esophagus or stomach.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10145540-DS-12 | 10,145,540 | 25,306,247 | DS | 12 | 2165-10-10 00:00:00 | 2165-10-12 18:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Tylenol / Advil
Attending: ___.
Chief Complaint:
positive blood cultures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M w/ hx of cirrhosis ___ PSC, decompensated with a history
of hepatic encephalopathy, ___ Disease, thrombocytopenia,
depression/anxiety, subdural hematoma, who presents with
intermitant fever/chills with abd pain found to have blood cx
positive from ___ with gram positive rods.
Patient reports feeling unwell since discharge with fevers (up
to 100.1), worsening pruritis, diarrhea (white mucus, no
melena/hematochezia) up to 5x/day, nausea, vomiting of food
(___). He has also noted worsening abdominal tenderness,
worse in RUQ/LLQ. He has also had dizziness but denies any
falls.
Of note, patient was recently in the hospital ___ for
hematemesis found to have portal gastropathy and esophagitis on
EGD. He had no recurrence of hematemesis and he was discharged
on BID omeprazole and prn zofran with follow-up in liver clinic.
In the ED initial vitals were: ___ 82 140/78 16 99%
- Labs were significant for lactate 2.1, LFTs: AST177, ALT91,
ALP380, Tbili 4.6, Alb 2.6, lipase 80, serum tox negative, wbc 3
(baseline 2-, h/h 9.8/28.2, platelets 23, INR 1.9.
- Patient was given
___ 18:20 PO Pantoprazole 40 mg
___ 18:20 IV Morphine Sulfate 5 mg Ke
___ 18:20 IV Ondansetron 4 mg
___ 18:31 IV Vancomycin 1000 mg
___ 19:50 IVF 1000 mL LR 500 mL
Vitals prior to transfer were: ___ 90 122/63 16 99% RA
On the floor, patient reports persistent pruritis and requests
protonix to help with gastritis as he says it has greatly
improved his symptoms in the past.
Past Medical History:
-Primary sclerosing cholangitis c/b cirrhosis w/ portal HTN, hx
hepatic encephalopathy
-Thrombocytopenia (baseline ~30s; ___ sequestration from portal
HTN)
-Anxiety/depression
-Substance abuse
-Hx bilateral traumatic subdurals sustained during
trauma(assault)
Social History:
___
Family History:
Father: ___ disease
Paternal GF: ___ dz
Father with melanoma and prostate cancer
Mother with hyperlipidemia
Physical Exam:
ADMISSION:
Vitals - T98.3 108/58 80 18 97%RA
GENERAL: NAD, oriented x 3
HEENT: AT/NC, EOMI, PERRL, mild scleral icterus, 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, soft, +BS, diffuse tenderness, worse in
ruq/rlq, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, no asterixis
SKIN: excoriations noted throughout with mild bruising
DISCHARGE:
Vitals - 98.3 96-108/30s-40s 55 18 99% RA
GENERAL: NAD, oriented x 3
HEENT: AT/NC, EOMI, PERRL, mild scleral icterus, pink
conjunctiva, MMM, good dentition
NECK: nontender supple neck, 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, soft, +BS, mild tenderness, worse in
ruq/rlq, no rebound/guarding
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: CN II-XII intact, no asterixis
SKIN: excoriations noted throughout with mild bruising, xerosis
improved
Pertinent Results:
ADMISSION LABS:
___ 05:45PM ___ PTT-42.3* ___
___ 05:45PM PLT COUNT-23*
___ 05:45PM NEUTS-67.1 ___ MONOS-6.1 EOS-2.7
BASOS-0.3
___ 05:45PM WBC-3.0* RBC-3.09* HGB-9.8* HCT-28.8* MCV-93
MCH-31.7 MCHC-34.1 RDW-15.9*
___ 05:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 05:45PM ALBUMIN-2.6* CALCIUM-8.4 PHOSPHATE-5.1*
MAGNESIUM-1.7
___ 05:45PM LIPASE-80*
___ 05:45PM ALT(SGPT)-91* AST(SGOT)-177* ALK PHOS-380*
TOT BILI-4.6*
___ 05:45PM GLUCOSE-109* UREA N-7 CREAT-0.7 SODIUM-139
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-25 ANION GAP-12
___ 05:56PM LACTATE-2.1*
DISCHARGE LABS:
___ 06:55AM BLOOD WBC-2.1* RBC-2.95* Hgb-9.4* Hct-27.9*
MCV-95 MCH-31.8 MCHC-33.6 RDW-15.7* Plt Ct-21*
___ 06:55AM BLOOD Glucose-81 UreaN-9 Creat-0.6 Na-140 K-4.1
Cl-110* HCO3-25 AnGap-9
___ 06:55AM BLOOD ALT-78* AST-110* AlkPhos-373*
TotBili-4.2*
___ 06:55AM BLOOD Calcium-8.1* Phos-3.7 Mg-2.0
___ 07:21AM BLOOD CRP-10.3*
IMAGING:
RUQUS ___:
IMPRESSION:
1. Nodular, shrunken liver. No focal mass however can be
distinguished in
the setting of background heterogeneity. Further assessment is
best made with
a contrast enhanced study.
2. Stigmata of portal hypertension with small volume ascites,
splenomegaly,
and multiple large portosystemic collateral vessels.
3. Patent portal vein with redemonstrated hepatofugal flow.
MRE ___:
IMPRESSION:
1. No evidence of inflammatory bowel disease.
2. Cirrhotic liver with massive splenomegaly and large varices.
MICRO:
___ 1:27 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 7:24 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 7:21 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 5:53 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 5:45 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
Brief Hospital Course:
___ yo M w/ hx of cirrhosis ___ PSC, decompensated with a history
of hepatic encephalopathy, ___ Disease, thrombocytopenia,
depression/anxiety, subdural hematoma, who presents with
intermitant fever/chills with abd pain presenting wtih gram
positive rod bacteremia from ___ with gram positive rods.
# Gram positive rod bacteremia: Is at risk for true bacteremia
given cirrhosis but felt by the microbiology lab to be a
contaminant given that they could identify a pathogenic species.
Serial blood cultures were NGTD and he was afebrile. Initially
covered with vancomycin but this was stopped prior to discharge.
# Abd pain/nausea/vomiting/diarrhea: Ddx includes known ___,
gastropathy, PVT (none seen recently on US), cholecystitis,
enteric infection such as Cdiff, bacterial enteritis, or viral
infection. Only had minimal ascites on recent US, likely not
enough to tap. Meselamine intolerance syndrome a consideration
but less likely. Repeat RUQUS unchanged, MRE negative for active
___ or other concerning pathology. Sucralfate was added
empirically. Pain seemed improved at discharge.
# Hx ___ disease: H/o ileitis, previously on ___ but not
since HS. Most ___ ___ neg for active dx. MRE was negative.
Continued mesalamine.
# Pruritis: Skin with xerosis. Unclear what component of this is
hyperbilirubinemia. Started on aquaphor and sarna as well as
ursodiol, with improvement in his symptoms.
# Portal gastropathy and esophagitis: Prior EGD demonstrated
varices at the gastroesophageal junction, portal gastropathy,
and esophagitis. Not on nadolol for hx bradycardia in the
setting of Grade I varices. Cont protonix.
# Hepatic encephalopathy: No e/o active encephalopathy. He was
given lactulose and rifaximin.
# Cirrhosis: Secondary to PSC. Per discharge summary ___ -
pt is not a transplant candidate at ___ given recent substance
abuse, behavioral problems, and poor follow up in liver clinic.
Also noted in dc summary ___ - after further discussion, the
patient admitted to using cocaine on ___ and ___ after
getting released from jail. He also was declined per OMR by ___
for psychosocial reasons. Plans to initiate care at ___. MELD
is ___, ___ B. DF is ___ and AST/ALT 2:1 ___enies ETOH
use. Encephalopathy ppx as above. No nadolol given bradycardia
during last admission. Previously prescribed furosemide 40 daily
and spironolactone 50mg daily, self-discontinued due to
polyuria. Consider SBP ppx in the future given ascitic protein
previously 0.4.
# Pancytopenia: Chronically low platelets and normocytic anemia,
with low WBCs over the last 3 months, though has been this low
intermittently over the last ___ years. Suspect this is related to
cirrhosis, splenic sequestration, mesalamine.
Transitional issues:
[ ] Continue to address need and adherence to furosemide 40
daily and spironolactone 50mg daily, not on them at discharge.
[ ] Followup with general GI and hepatology, pt will be
establishing liver care at ___
[ ] Sucralfate added for abdominal pain with good effect
[ ] Sarna, aquaphor, ursodiol added for pruritis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 30 mL PO TID
2. Rifaximin 550 mg PO BID
3. Apriso (mesalamine) 1.5 g oral daily
4. Omeprazole 40 mg PO BID
5. Ondansetron ___ mg PO Q8H:PRN nausea
6. Ranitidine 150 mg PO BID
Discharge Medications:
1. Apriso (mesalamine) 1.5 g oral daily
2. Lactulose 30 mL PO TID
3. Rifaximin 550 mg PO BID
4. Aquaphor Ointment 1 Appl TP BID
RX *white petrolatum [Aquaphor with Natural Healing] 41 % 1
application to affected areas twice a day Refills:*0
5. Sarna Lotion 1 Appl TP TID:PRN itching
RX *camphor-menthol [Anti-Itch (menthol/camphor)] 0.5 %-0.5 % 1
application to affected areas three times a day Refills:*0
6. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp
#*60 Tablet Refills:*0
7. Ursodiol 300 mg PO BID
RX *ursodiol 300 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
8. Omeprazole 40 mg PO BID
9. Ondansetron ___ mg PO Q8H:PRN nausea
10. Ranitidine 150 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Gram positive rod bacteremia, likely contaminant
Abdominal pain
Cirrhosis
PSC
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted with abdominal pain and a positive blood
culture. The blood culture was likely a contaminant and not a
true pathogen. The source of your abdominal pain was not clear
but may be due to the inflammation in your stomach from
cirrhosis. We tested you for ___ but did not find any
evidence of active infection.
Please followup with your outpatient providers and continue to
abstain from alcohol and drugs.
Followup Instructions:
___
|
10145540-DS-13 | 10,145,540 | 26,540,270 | DS | 13 | 2165-12-25 00:00:00 | 2165-12-25 20:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Tylenol / Advil
Attending: ___
Chief Complaint:
abd pain, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M w/ hx of cirrhosis ___ PSC, decompensated with a history
of hepatic encephalopathy, ___ Disease, thrombocytopenia,
depression/anxiety, subdural hematoma, who presents with
intermitant fever/chills with abd pain
The patient states that over over the past few days he has been
having abdominal pain in a band like region in the epigastric
area, in addition to fevers as high as ___ F, and
nausea/vomiting. He does endorse softer stools but no overt
diarrhea. He has had recent sick contacts. No previous abdominal
surgeries. Has had to have a paracentesis x1 for large volume
ascites.
Of note the patient was admitted in ___ with abdominal pain.
A diagnosis was not definitively made at this time, but his pain
may have been due to his known ___ and was improved on
discharge. He was also noted to have gram positive rod
bacteremia initially treated with vancomycin however subsequent
bld cx were negative and thus this was though to be a
contaminant. Shortly prior to this, the patient was in the
hospital ___ for hematemesis found to have portal
gastropathy and esophagitis on
EGD.
In the ED, initial vitals were 102.8 108 144/62 16 100% ra
- Labs notable for: plt 14 (baseline ___, AST/ALT/ALP/Tbili
68/42/294/5.1 (close to baseline), INR 2.2 (baseline 2.0),
lactate 2.0
- CXR: Subtle opacities project over bilateral lower lung zones
are more conspicuous relative to prior examinations concerning
for early airspace infectious process.
- RUQ u/s: splenomegaly, without ascites, no PVT
- Pt given vanc/cefepime
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
-Primary sclerosing cholangitis c/b cirrhosis w/ portal HTN, hx
hepatic encephalopathy
-Thrombocytopenia (baseline ~30s; ___ sequestration from portal
HTN)
-Anxiety/depression
-Substance abuse
-Hx bilateral traumatic subdurals sustained during
trauma(assault)
-___ disease
Social History:
___
Family History:
Father: ___ disease
Paternal GF: ___ dz
Father with melanoma and prostate cancer
Mother with hyperlipidemia
Physical Exam:
>> Admission Physical Exam:
VS: T 99.4 122/58 84 18 100% RA
General: alert, oriented, in distress secondary to pain
HEENT: NC/AT, EOMI, mild scleral icterus
Neck: supple
CV: RRR, no m/r/g
Lungs: CTAB, no wheezes, rales, or rhonchi
Abdomen: voluntary guarding, no peritoneal signs, no rebound
tenderness
GU: deferred
Ext: warm and well perfused, no ___ edema
Neuro: alert, oriented
.
>> Discharge Physical Exam :
VS: T 98.8 124 / 60 57 18 97 RA
General: Alert, oriented x 3. Laying in bed, no acute distress.
Conversing well.
HEENT: NC/AT, EOMI, pale appearing, no scleral icterus. MMM.
Neck is supple. No JVD.
CV: RRR, no m/r/g appreciated.
Lungs: CTAB, no wheezes, rales, or rhonchi
Abdomen: Voluntary guarding improved. Tenderness in the RUQ.
Tenderness in the lower quadrants minimal. No rebound/guarding.
Abdomen soft, no peritoneal signs.
GU: deferred
Ext: No ___ edema.
Pertinent Results:
>> Admission Physical Exam:
___ 12:10AM BLOOD WBC-4.3# RBC-3.49* Hgb-10.2* Hct-29.6*
MCV-85# MCH-29.2 MCHC-34.5 RDW-16.1* Plt Ct-14*
___ 12:10AM BLOOD ___ PTT-43.9* ___
___ 12:10AM BLOOD ALT-42* AST-68* AlkPhos-294* TotBili-5.1*
___ 12:10AM BLOOD Albumin-3.0*
___ 09:40AM BLOOD Calcium-7.7* Phos-2.6* Mg-1.6
___ 12:10AM BLOOD CRP-17.0*
___ 12:25AM BLOOD Lactate-2.0
.
>> Discharge Physical Exam:
___ 05:41AM BLOOD WBC-1.4* RBC-3.12* Hgb-8.8* Hct-27.3*
MCV-87 MCH-28.3 MCHC-32.4 RDW-16.3* Plt Ct-12*
___ 05:41AM BLOOD ___ PTT-49.0* ___
___ 05:41AM BLOOD Glucose-92 UreaN-5* Creat-0.8 Na-138
K-3.9 Cl-108 HCO3-23 AnGap-11
___ 05:41AM BLOOD ALT-32 AST-55* AlkPhos-243* TotBili-3.3*
___ 05:41AM BLOOD Albumin-2.4* Calcium-7.6* Phos-3.2 Mg-2.1
.
>> Pertinent Reports:
IMPRESSION:
Subtle opacities project over bilateral lower lung zones are
more conspicuous relative to prior examinations concerning for
early airspace infectious process.
RUQ
IMPRESSION:
1. Nodular shrunken liver with heterogeneous hepatic parenchyma
in keeping with cirrhosis. Numerous portosystemic walls and
reversal of flow within a patent portal vein reflects portal
hypertension, similar to examination dated ___. No
ascites.
2. Splenomegaly.
Last EGD: ___ Impression: Varices at the gastroesophageal
junction Erythema, congestion and mosaic appearance in the
fundus and stomach body compatible with portal gastropathy
Erythema and linear erosions in the lower third of the esophagus
compatible with esophagitis Otherwise normal EGD to third part
of the duodenum
CT Abdomen: 1. No evidence of acute infectious process within
the abdomen or pelvis. 2. Cirrhosis with sequelae of severe
portal hypertension, unchanged from ___.
Brief Hospital Course:
___ year old male, with h/o of PSC c/b liver cirrhosis c/b
hepatic encephalopathy, ascites, and esophageal varices, also
past history of ___ Disease, depression/anxiety, presenting
with fevers and worsened abdominal pain:
.
>> ACTIVE ISSUES:
# Abdominal Pain: Patient was found to be febrile in both the
Emergency Department, and upon arrival to the floor. Given
patient's non-specific nature, history of cirrhosis and PSC,
patient underwent CT abdominal for assessment of intra-abdominal
process. Patient found to have an elevated bilirubin, and
therefore first started on IV vancomycin and Zosyn, and this was
narrowed to IV Zosyn already. Patient was continued on his home
medications, including sucralfate, and both PPI and H2 blocker.
Patient's CT scan did not show any significant abdominal
infectious process, and infectious workup including cultures
performed. Patient had rapid improvement in abdominal symptoms,
tolerating PO intake, and requiring minimal oral pain relievers.
MRCP was initially going to be pursued to identify any
strictured hepatic ducts, however given rapid improvement in
bilirubin (under baseline), and improvement in abdominal
symptoms, patient was changed to oral antibiotic regimen for
presumed 10 day course.
.
# Cirrhosis ___ PSC: Patient's prior history was from ascites
and hepatic encephalopathy, and prior EGD without varices.
Patient's prior CT scan also showed large portal gastropathy and
RP, and portal HTN found to be unchanged compared with prior.
Patient was continued on maintenance rifaxamin and lactulose, no
evidence of encephalopathy during admission. Patient was also
continued on ursodiol.
.
# Thrombocytopenia: Patient found to be at baseline, ___ to
sequestration and enlarging splenomegaly. Patient had no signs
of bleeding during hospital stay.
.
# GERD: Patient was continued on home omeprazole and ranitidine.
.
# Substance Abuse: Patient has a history of daily marijuana use
for nausea/vomiting in the past.
.
>> TRANSITIONAL ISSUES:
1) F/U Liver enzymes within ___ weeks
2) Consider MRCP if recurrence of symptoms or fever
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apriso (mesalamine) 1.5 g oral daily
2. Lactulose 30 mL PO TID
3. Rifaximin 550 mg PO BID
4. Aquaphor Ointment 1 Appl TP BID
5. Sarna Lotion 1 Appl TP TID:PRN itching
6. Sucralfate 1 gm PO QID
7. Ursodiol 300 mg PO BID
8. Omeprazole 40 mg PO BID
9. Ondansetron ___ mg PO Q8H:PRN nausea
10. Ranitidine 150 mg PO BID
Discharge Medications:
1. Lactulose 30 mL PO TID
2. Omeprazole 40 mg PO BID
3. Ondansetron ___ mg PO Q8H:PRN nausea
4. Ranitidine 150 mg PO BID
5. Rifaximin 550 mg PO BID
6. Sarna Lotion 1 Appl TP TID:PRN itching
7. Sucralfate 1 gm PO QID
8. Ursodiol 300 mg PO BID
9. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*17 Tablet Refills:*0
10. Acetaminophen 650 mg PO Q8H:PRN pain
OK to take up to 2 grams (2000mg) daily
11. Apriso (mesalamine) 1.5 g oral daily
12. Aquaphor Ointment 1 Appl TP BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Fever
SECONDARY: Cirrhosis, Primary Sclerosing Cholangitis
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 fever and abdominal pain.
A CT-scan of your abdomen did not show any major active
abnormalities, and you improved quickly with antibiotics. We
recommend you continue antibiotics for a total of 7 days and
follow up with your ___ doctors very ___.
Followup Instructions:
___
|
10145540-DS-14 | 10,145,540 | 21,436,784 | DS | 14 | 2167-02-26 00:00:00 | 2167-02-27 13:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Tylenol / Advil
Attending: ___
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
___ - EGD
History of Present Illness:
___ male with complex past medical history significant
for a primary sclerosing cholangitis with cirrhosis (MELD 19,
___ Class likely C) and recurrent episodes of hepatic
encephalopathy, ___ disease, and polysubstance abuse, who
was brought in via EMS for safety evaluation.
Per patient, he has been encephalopathic recently and was put
on rifaximin and lactulose by his PCP, who also outlined a
cellulitis on his LLE 2 days ago. He was apparently visited by
EMS on evening of presentation per his parents' request to
evaluate his safety at home. He was taken to ___ ED for
further evaluation.
On discussion with mother, she states that he has had a month
of worsening mental status characterized by increasing
agitation, paranoia, and irrational behavior with 1 day of acute
worsening. Over the weekend he was seen by his PCP who outlined
___ lesion thought to be cellulitis and is taking antibiotics as
outpatient (patient did not recall the name of the antibiotic on
exam).
In the ED, initial vitals were: 100.0 75 115/47 11 97% RA.
Labs were notable for Hg 10.6 and platelets 22 (at baseline).
LFTs notable for ALT 70, AST 118, alk phos 437, tbili 3.5,
improved on repeat ___. Lipase 39. Albumin 3.0. Tox screen
positive for benzodiazepines, opioids, and cocaine.
Imaging was notable for CT head without acute intracranial
abnormality, RUQ limited but no evidence of acute biliary
infection, and CXR negative for infection.
In the ED, he initially required 5mg IM Haldol for agitation.
He also received multiple doses of 0.5mg PO lorazepam. He was
started on IV octreotide and a PPI drip due to prior history of
varices. On the evening on ___ he developed nausea and
vomiting, with episodes Q1h and was treated with IV Zofran.
On the floor, initial vitals were 98.3 115/43 68 18 100% 2L.
Past Medical History:
-Primary sclerosing cholangitis c/b cirrhosis w/ portal HTN, hx
hepatic encephalopathy
-Thrombocytopenia (baseline ~30s; ___ sequestration from portal
HTN)
-Anxiety/depression
-Substance abuse
-Hx bilateral traumatic subdurals sustained during
trauma(assault)
-___ disease
Social History:
___
Family History:
Father: ___ disease
Paternal GF: ___ dz
Father with melanoma and prostate cancer
Mother with hyperlipidemia
Physical Exam:
============================
PHYSICAL EXAM ON ADMISSION
============================
Vital Signs: 98.3 115/43 68 18 100% 2L
General: Alert, oriented, no acute distress, tired appearing
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, neck
supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended
GU: No foley
Ext: Warm, well perfused, 2+ pulses, left lower extremity
purpuric nonblanching rash over shin
Neuro: CNII-XII grossly intact, moving all extremities, no
asterixis
============================
PHYSICAL EXAM ON DISCHARGE
============================
Vital Signs: T 98.1 HR 60 BP 100/53 RR 18 97 RA
General: Alert, no acute distress
HEENT: Sclera very mild icterus, MMM, NCAT
Lungs: breathing comfortably
GU: No foley
Neuro: Alert, oriented, speech fluent, no focal deficits, moving
all extremities with purpose
Psych: awake, alert, calm
Pertinent Results:
=========================
LABS ON ADMISSION
=========================
___ 10:25PM BLOOD WBC-4.6# RBC-3.76* Hgb-10.6* Hct-32.0*
MCV-85 MCH-28.2 MCHC-33.1 RDW-18.2* RDWSD-56.5* Plt Ct-22*#
___ 10:25PM BLOOD Neuts-72.7* Lymphs-18.2* Monos-6.1
Eos-2.4 Baso-0.4 Im ___ AbsNeut-3.31 AbsLymp-0.83*
AbsMono-0.28 AbsEos-0.11 AbsBaso-0.02
___ 05:25PM BLOOD ___ PTT-36.2 ___
___ 10:25PM BLOOD Glucose-87 UreaN-14 Creat-0.9 Na-137
K-3.2* Cl-102 HCO3-25 AnGap-13
___ 10:25PM BLOOD Glucose-87 UreaN-14 Creat-0.9 Na-137
K-3.2* Cl-102 HCO3-25 AnGap-13
___ 10:25PM BLOOD ALT-70* AST-118* AlkPhos-437*
TotBili-3.5*
___ 10:25PM BLOOD Lipase-34
___ 10:25PM BLOOD Albumin-3.2*
___ 10:24PM BLOOD Ammonia-69*
___ 10:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:05AM URINE bnzodzp-POS* barbitr-NEG opiates-POS*
cocaine-POS* amphetm-NEG oxycodn-NEG mthdone-NEG
___ 12:05AM URINE Color-Yellow Appear-Clear Sp ___
___ 12:05AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
=========================
PERTINENT INTERVAL LABS
=========================
___ 04:50AM BLOOD Ret Aut-2.2* Abs Ret-0.07
___ 08:38PM BLOOD TSH-0.23*
___ 08:38PM BLOOD T4-5.6
=========================
LABS ON DISCHARGE
=========================
___ 06:00AM BLOOD WBC-2.5* RBC-3.29* Hgb-9.4* Hct-29.0*
MCV-88 MCH-28.6 MCHC-32.4 RDW-18.4* RDWSD-60.1* Plt Ct-17*
___ 06:00AM BLOOD ___ PTT-40.4* ___
___ 06:00AM BLOOD Glucose-87 UreaN-10 Creat-0.8 Na-135
K-4.0 Cl-102 HCO3-29 AnGap-8
___ 06:00AM BLOOD ALT-73* AST-111* AlkPhos-371*
TotBili-2.4*
___ 06:00AM BLOOD Calcium-7.5* Phos-3.7 Mg-1.6
=========================
MICRO
=========================
___ - Blood culture x2 - pending
___ - Urine culture - no growth
=========================
IMAGING/STUDIES
=========================
ECG ___
Sinus rhythm. Prominent early R wave progression. Compared to
the previous
tracing of ___ there is no significant diagnostic change.
QTC 489/508
ECG ___
Baseline artifact. Sinus arrhythmia. Monomorphic ventricular
premature
beats. Non-diagnostic Q waves in leads I and aVL. Early R wave
progression. Prominent precordial voltage with Q waves in leads
V3-V6, probably septal in origin. Compared to the previous
tracing of ___ the ventricular premature beats are new.
Prominent voltage persists, may be normal for age. However,
clinical correlation is suggested. The QTc interval remains
prolonged, longer than seen on ___. Clinical correlation is
suggested.
QTC 475/496
ECG ___
Sinus bradycardia. Compared to the previous tracing of ___
the rate is
slower. Ventricular premature beats are no longer present.
Precordial voltage is somewhat less. Q-T interval prolongation
persists. Clinical correlation is suggested.
QTC 483
CT Head WO Contrast ___
1. No acute intracranial process.
2. Left external auditory canal opacification, with no evidence
of acute
fracture on this head CT. .
3. Mild paranasal sinus inflammation.
RUW US with Doppler ___
FINDINGS:
Limited grayscale images of the upper abdomen demonstrate an
unremarkable
gallbladder, with no evidence of gallstones, wall thickening, or
pericholecystic fluid.
The exam was terminated secondary to patient discomfort and
continuing emesis during image acquisition.
IMPRESSION:
1. Incomplete exam was terminated early due to patient
discomfort and ongoing emesis during image acquisition. No
Doppler images could be acquired.
2. Unremarkable gallbladder.
CXR ___
No definite focal consolidation to suggest pneumonia. No acute
cardiopulmonary process.
EGD ___
Esophagus:
Protruding Lesions Two cords of grade ___ varices without high
risk features were seen in the lower esophagus.
Stomach:
Mucosa: Mosaic appearance of the mucosa was noted in the fundus.
These findings are compatible with portal hypertensive
gastropathy.
Other No gastric varices were seen.
Duodenum: Normal duodenum.
Impression:
Esophageal varices
Mosaic appearance in the fundus compatible with portal
hypertensive gastropathyNo gastric varices were seen.
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
___ male with complex past medical history significant
for a primary sclerosing cholangitis with cirrhosis (MELD 19,
___ Class likely C) and recurrent episodes of hepatic
encephalopathy, ___ disease, and polysubstance abuse, who
presented with acute altered mental status.
# Altered mental status.
The patient was brought by EMS to the ED due to his parent's
concern about incresaigl altered mental status at home with
lability, impulsivity and aggression. Tox screen found to be
positive for opiates, benzodiazepines (both of which he is
prescribed as an outpatient) as well as cocaine. He was seen by
psychiatry who recommended ___ status. His acutely
altered manic epside was though likely secondary to cocaine
intoxication. There was no evidence of hepatic encephalopathy,
and infectious workup was unremarkable. He was re evaluated by
psychiatry throughout his hospital stay. He had improvement in
his mental status with good behavioral control and has been
cooperative with his care, with denial o suicidal ideation,
inent or plan. It was determined that he could be discharged
home with close suppot from his family with intake for a partial
hospitalization program to start next week. On discharge the
patient was placed on lorazepam ___ m TID PRN for anxiety, and
started Seroquel ___ m BID PRN for agitation.
# Nausea/Vomiting/Question of coffee round emesis: Patient had
an episode o dark red emesis in the ED concerning for GI bleed
in setting of history of prior varices (1 cord of grade 1
varices on previous ED). The patient ad continued abdominal pain
and nausea but was unable to tolerate RUQ US. The patient
underwent repeat EGD with two cords o grade ___ varices without
high risk features seen in the lower esophagus, as well as
findings compatible with portal hypertensive gasropathy but no
gastric varices. The patient was continued on a PPI with no
further episodes of bleeding.
# Left sided hearing loss: The patient noted left sided hearing
loss during the admission. CT Head in the ED was negative for
fracture or acute bleed. He was noted to have bleeding within
the left ___ canal. He was evaluated by ENT who thought that the
etiology was likely secondary to Qtip trauma and wax. He was
prescribed Ciprodex drops BID for 10 day course, with follow up
exam in ___ weeks with audiogram.
# Systolic murmur: The patient was noted to have a systolic
murmur an prominent P2 on examination. This was thought likely
secondary to his underlying cirrhosis. Suspicion for
endocarditis was very low, and blood cultures remained negative,
thus TTE was held in accordance wit patient's wishes.
# Rash on left anterior shin: Patient arrived with rash on left
anterior shin that had been previously evaluated by PCP who
prescribed ___ for cellulitis. The patient was evaluated by
dermatology, and felt the rash not to be consistent with
cellulitis and was likely traumatic in the setting of
thrombocytopenia. He was given topical Vaseline.
# Transaminitis/cirrhosis secondary to primary sclerosing
cholangitis: There was no evidence of decompensation or hepatic
encephalopathy. The patient was continued on Lasix,
spironolactone, lactulose and rifaximin. Patient had stable but
low platelet count throughout the admission without evidence of
active bleeding.
TRANSITIONAL ISSUES:
====================
[ ] Please discuss restarting urosdiol and or medication for
___ at next GI meeting, as patient currently not taking
[ ] repeat CBC should be checked at time of PCP follow up. ___
9.4 and platelets 17 at time of discharge
[ ] Patient discharged on ___ drops for total of 10 day course
(___)
[ ] stopped clonazepam and diazepam
[ ] changed lorazepam dose to 1 mg TID PRN anxiety
[ ] started Seroquel 25 mg BID PRN agitation
[ ] Patient will need follow up with ENT in 1 week with
audiogram for further evaluation of left sided hearing loss
[ ] Consider outpatient TFTs given low TSH but normal T4
[ ] Patient discharged with plan for dual diagnosis day program:
Intake Appointment
___ @ 9 a.m.
Arbour HRI
General Adult Partial Hospital
___
___ to reschedule
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 15 mL PO BID:PRN constipation
2. Ondansetron 8 mg PO Q8H:PRN nausea
3. Ranitidine 150 mg PO BID
4. Rifaximin 550 mg PO BID
5. Morphine Sulfate ___ 15 mg PO Q6H:PRN pain
6. Cephalexin 500 mg PO Q6H
7. Diazepam 10 mg PO QHS:PRN muscle spasm
8. LORazepam 1 mg PO Frequency is Unknown anxiety
9. ClonazePAM 1 mg PO BID
10. Spironolactone 50 mg PO DAILY
11. Furosemide 40 mg PO DAILY
12. Omeprazole 40 mg PO DAILY
Discharge Medications:
1. Furosemide 40 mg PO DAILY
2. Lactulose 15 mL PO BID:PRN constipation
3. Morphine Sulfate ___ 15 mg PO Q6H:PRN pain
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Rifaximin 550 mg PO BID
6. Spironolactone 50 mg PO DAILY
7. Ciprodex (ciprofloxacin-dexamethasone) 0.3-0.1 % otic BID
Duration: 9 Days
4 drops twice daily
RX *ciprofloxacin-dexamethasone [Ciprodex] 0.3 %-0.1 % 4 DROPS
LEFT ___ twice a day Disp ___ Milliliter Milliliter Refills:*0
8. Ranitidine 150 mg PO BID
9. Omeprazole 40 mg PO DAILY
10. QUEtiapine Fumarate 25 mg PO BID PRN agitation
RX *quetiapine 25 mg 1 tablet(s) by mouth twice a day Disp #*10
Tablet Refills:*0
11. LORazepam 1 mg PO TID:PRN agitation/.anxiety
RX *lorazepam 1 mg 1 tablet by mouth three times a day Disp #*14
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
# Altered mental status
# Left sided hearing loss
# Esophageal varices
# Portal hypertensive gastropathy
# Thrombocytopenia
# Cirrhosis secondary to primary sclerosing cholangitis
# 2 cords grade ___ varices
# Portal hypertensive gastropathy
# Substance use
# Mood disorder
# Systolic murmur
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were brought to the hospital by EMS because your family was
concerned about your safety. In the emergency department you had
an episode concerning for throwing up blood. You had an upper
endoscopy which showed esophageal varices, two cords of grade
___ varices which is slightly progressed from your previous
endoscopy. There was also evidence of a process called portal
hypetensive gastropathy, which can be seen with cirrhosis. There
was no evidence of bleeding.
You were re evaluated by the psychiatry team throughout the
hospitalization. After discussion, it was decided the that you
will go home and will start a day program next ___.
Your updated medications and appointments are listed below.
We wish you the best!
- Your ___ Care Team
Followup Instructions:
___
|
10145540-DS-16 | 10,145,540 | 28,792,447 | DS | 16 | 2168-08-18 00:00:00 | 2168-08-22 16:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Tylenol / Advil
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Diagnostic paracentesis ___
History of Present Illness:
This is a ___ yo man with cirrhosis (due to primary sclerosing
cholangitis, complicated by hepatic encephalopathy, ascites, and
bleeding varices s/p banding "a while ago"), ___ disease,
and
polysubstance abuse who presents with 4 days of N/V/D and
right-sided abdominal pain. Patient has some difficulty
relating
the history, as he feels "confused" and is forgetful about what
happened before ___ of last week (___).
Pt began with nausea/vomiting around ___ that got worse with
rolling onto his left side, or with bending over. He was
vomiting and having nonbloody nonmelenic diarrhea ___ per day
each. The nausea/vomiting was provoked by food intake and by
positional changes; it was not relieved with attempted tums or
pepto-bismol at home. Shortly after this, patient began to have
some right-sided abdominal pain (worst in the RUQ) with an
underlying "constant" component and intermittent "knife-like
stabbing" every ___ minutes. This pain was also provoked by
eating, and it was not relieved with the above medicines. He
has
not had any recent travel, eaten new foods, or had ill contacts
prior to the development of these symptoms.
Patient came to the ED on ___ because he was feeling "more
confused," and that he sometimes gets like this with his hepatic
encephalopathy. Notably he was less able to tolerate his
medications like rifaximin and lactulose prior to arrival.
In the ED initial vitals: T 98.8 BP 142/82 HR 93 RR 16 O2 98%
on
RA
- Exam notable for: Not recorded.
- Imaging notable for:
CXR PA AND LATERAL (___):
RLL pneumonia.
LIVER OR GALLBLADDER US (___):
1. Nodular shrunken liver with heterogenous hepatic parenchyma,
consistent
with known cirrhosis, now decompensated given large volume
ascites.
2. Reversal of flow within a patent portal vein, as well as
numerous
portosystemic collaterals with reversal of flow, demonstrating
worsening portal hypertension compared to prior studies.
3. Moderate to severe ascites.
4. Splenomegaly.
- Labs notable for: Lactate 3.4 on arrival -> 1.2; Diagnostic
paracentesis without SBP (though with 12 mesothelial cells
favored reactive); clean UA; ALT 49, AST 58, ALP 301, Tbili 3,
albumin 2.1; Na 130, Cr 0.5; Hb 10.2, Plt 29; influenza swab
negative.
- Patient was given:
___ 12:08 IV Metoclopramide 10 mg ___
___ 13:29 IV Morphine Sulfate 4 mg ___
___ 14:46 IV CefTRIAXone ___ Started
___ 15:16 IV Azithromycin ___ Started
___ 15:16 IV CefTRIAXone 1 gm ___ Stopped
(___)
___ 16:20 IV Azithromycin 500 mg ___ Stopped
(1h ___
___ 19:03 IV Morphine Sulfate 4 mg ___
___ 20:41 PO/NG Rifaximin 550 mg ___
___ 08:22 PO/NG Spironolactone 200 mg ___
___ 08:22 PO/NG Rifaximin 550 mg ___
___ 08:22 PO/NG Ranitidine 150 mg ___
___ 09:49 PO Aluminum-Magnesium Hydrox.-Simethicone 30 mL
___
___ 09:49 PO Donnatal 5 mL ___
___ 09:49 PO Lidocaine Viscous 2% 10 mL ___
___ 14:19 PO OxyCODONE (Immediate Release) 5 mg
___
___ 16:28 IV CefTRIAXone (1 gm ordered) ___
Started
___ 16:28 PO/NG Azithromycin 250 mg ___
___ 16:53 IV CefTRIAXone ___ Stopped in
Other
Location
- Vitals prior to transfer: T 98.3 BP 118/65 HR 68 RR 18 O2
100%
on RA
On arrival to the floor, patient endorses the above symptoms.
He
states he feels "like I'm encephalopathic."
Patient notes a subjective fever 3d ago. He denies any chills,
chest pain, SOB, hematochezia, melena, hematemesis, dysuria,
hematuria, lightheadedness, and focal weakness.
REVIEW OF SYSTEMS:
As per HPI. Otherwise a 10-point ROS is negative.
Past Medical History:
-Primary sclerosing cholangitis c/b cirrhosis w/ portal HTN, hx
hepatic encephalopathy, reported bleeding varices, and ascites
(last drained several months prior to arrival).
-Thrombocytopenia (baseline ~30s; ___ sequestration from portal
HTN)
-Substance abuse
-Hx bilateral traumatic subdurals sustained during
___ assault)
-___ disease (not currently on medicines)
Social History:
___
Family History:
Father: ___ disease
Paternal GF: ___ dz
Father with melanoma and prostate cancer
Mother with hyperlipidemia
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T 98.9 BP 113/71 HR 80 RR 18 O2 96% on RA
GENERAL: Thin Caucasian male lying on his right side in bed.
Eyes closed on my entry but rouses to light voice. In no acute
distress.
HEENT: Sclerae anicteric, PERRL, EOMI.
NECK: Supple. JVP estimated at 6-7cm H2O while lying at 30
degrees.
CARDIAC: RRR with intermittent ectopy, normal S1/S2. Systolic
ejection murmur best auscultated at the LLSB, without radiation
to the axilla; Pt states he has been told he had this before.
PULMONARY: Decreased breath sounds from the R midfield down
with
crackles there. Dullness to percussion at the R midfield at
base.
ABDOMEN: Hyperactive bowel sounds. Abdomen is soft, mildly
distended, tender to palpation in all four quadrants. Pt
endorses worst pain in the RUQ > RLQ. +rebound tenderness in
all
four quadrants, though this is somewhat distractable. No
obturator sign.
GENITOURINARY: No foley
EXTREMITIES: Warm and well perfused. No peripheral edema.
SKIN: Gynecomastia appreciated. No spider angiomata noted.
NEUROLOGIC: A&O x3, albeit with slow speech. Mild asterixis.
PSYCHIATRIC: Quiet and appropriately interactive.
DISCHARGE PHYSICAL EXAM:
VS: T:98.7 BP:103 / 66 P:86 RR:18 POx:96% on Ra
GENERAL: Thin Caucasian male lying in bed, alert and oriented.
HEENT: Sclerae anicteric, PERRL, EOMI.
CARDIAC: RRR, no m/r/g
PULMONARY: CTAB. Breathing comfortably on room air without the
use of accessory muscles.
ABDOMEN: soft, mildly distended, mild tenderness to palpation in
RLQ, no rebound tenderness. No guarding this morning.
EXTREMITIES: Warm and well perfused. 1+ bilateral pitting ___
edema to the lower ___ of the shin.
SKIN: Gynecomastia appreciated. No spider angiomata noted.
NEUROLOGIC: A&O x3,
PSYCHIATRIC: flat affect, pleasant.
Pertinent Results:
ADMISSION LABS:
===============
___ 09:50AM BLOOD WBC-6.7# RBC-3.18* Hgb-10.0* Hct-29.8*
MCV-94 MCH-31.4 MCHC-33.6 RDW-18.9* RDWSD-64.2* Plt Ct-27*
___ 09:50AM BLOOD Plt Ct-27*
___ 11:17AM BLOOD ___ PTT-40.7* ___
___ 09:50AM BLOOD Glucose-131* UreaN-12 Creat-0.7 Na-128*
K-4.1 Cl-94* HCO3-23 AnGap-11
___ 09:50AM BLOOD ALT-57* AST-78* LD(LDH)-433* AlkPhos-296*
TotBili-3.9* DirBili-1.9* IndBili-2.0
___ 09:50AM BLOOD Albumin-2.1* Calcium-7.5* Phos-2.4*
Mg-2.0
___ 11:13AM BLOOD Lactate-3.4*
PERTINENT LABS:
===============
___ 06:02AM BLOOD CRP-19.7*
MICRO:
=====
_________________________________________________________
___ 2:43 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
__________________________________________________________
___ 2:51 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 1:45 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
__________________________________________________________
___ 9:45 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 12:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING/RESULTS:
================
___: Liver or Gallbladder Ultrasound
1. Nodular, shrunken liver with heterogenous hepatic parenchyma
and large
volume ascites, consistent with decompensated cirrhosis.
2. Reversal of flow within a patent portal vein, as well as
numerous
portosystemic collaterals with reversal of flow, demonstrating
worsening
portal hypertension compared to prior studies.
3. Large volume ascites and partially visualized right pleural
effusion.
4. Splenomegaly.
___: Chest X ray
Right lower lobe pneumonia. Probable tiny right pleural
effusion.
___: CT Abdomen and Pelvis with Contrast
1. Gastric distension and fluid-filled colon suggests
gastroenteritis of an
infectious/inflammatory etiology. No bowel obstruction. No
evidence of active
___ flare.
2. No CT evidence of acute inflammation involving the biliary
tree.
3. Large right pleural effusion with near collapse of the imaged
right lower
lobe. Appropriate enhancement of the collapsed portion of lung
favors
atelectasis over infection.
4. Re-demonstration of cirrhosis with sequela of severe portal
hypertension,
similar to ___.
___: Abdomen supine and erect
Nonspecific gas pattern without clear evidence of free air or
obstruction. If
there is concern for obstruction or pneumoperitoneum, may
consider CT for
further characterization.
___: Chest (portable)
Compared to chest radiographs since ___, most recently ___.
Moderate right pleural effusion is larger, obscuring the right
lower lobe.
Interstitial abnormality in the left lung has a nodular quality.
Findings are
concerning for atypical pneumonia, including possible miliary
tuberculosis.
Heart size top-normal, increased since ___.
___: Chest Pa and Lateral
Improvement in right pleural effusion, now small. Patchy
opacity at the right
lung base may represent resolving atelectasis versus pneumonia.
Previously
described faint nodular interstitial abnormality of the left
lung appears
slightly less conspicuous. Attention on follow-up.
Cardiomediastinal silhouette appears unchanged. No
pneumothorax.
DISCHARGE LABS:
===============
___ 06:01AM BLOOD WBC-2.5* RBC-2.46* Hgb-7.7* Hct-23.7*
MCV-96 MCH-31.3 MCHC-32.5 RDW-16.8* RDWSD-58.9* Plt Ct-21*
___ 06:01AM BLOOD ___ PTT-41.5* ___
___ 06:01AM BLOOD Glucose-88 UreaN-11 Creat-0.8 Na-137
K-4.1 Cl-103 HCO3-25 AnGap-9*
___ 06:01AM BLOOD Albumin-2.1* Calcium-7.5* Phos-3.6 Mg-1.8
Brief Hospital Course:
Mr. ___ is a ___ with PMHx cirrhosis (due to primary
sclerosing cholangitis, complicated by hepatic encephalopathy,
ascites, and reported bleeding varices) who presented with a
chief complaint of nausea, vomiting, and right-sided abdominal
pain that began ___ days prior to admission likely secondary to
pneumonia as well as unclear etiology of abdominal pain.
ACTIVE ISSUES:
# COMMUNITY-ACQUIRED PNEUMONIA:
# pleural effusion
Community-acquired pneumonia diagnosis was based on focal
infiltrate on chest x-ray, decreased breath sounds, and
productive cough. The patient was satting well on room air, but
this could have been a precipitant of his nausea/vomiting as
well as hepatic encephalopathy (see below). While CT read with
low likelihood of pneumonia, we treated with ceftriaxone and
azithromycin for 5 days total given his symptoms and risk of
decompensation. Patient also with right sided pleural effusion
likely secondary to hepatic hydrothorax that decreased in size
with active diuresis.
# HEPATIC ENCEPHALOPATHY:
Based on asterixis and slowed speech on admission; it improved
over his admission with lactulose and rifaximin. RUQUS without
portal venous thrombosis, though notable for reversal of flow
and portosystemic collaterals (concerning for worsening portal
hypertension); given concern for possible pneumonia on CXR, he
was treated for pneumonia as above. Furthermore, negative for
spontaneous bacterial peritonitis. Urine and blood cultures
negative. Tox screen only positive for opiates and oxycodone,
which he was given in the ED. Pneumonia could have precipitated
his confusion. In discussion with Pt's father, patient develops
these episodes of encephalopathy when he is on drugs or
otherwise intoxicated.
# ABDOMINAL PAIN and
# NAUSEA/VOMITING/DIARRHEA:
Patient with abdominal pain, nausea, and rebound. Possibly in
the setting of pneumonia as above versus viral etiology given
nonbloody, relatively food-related. C. difficile and norovirus
were negative. Diagnostic paracentesis negative for SBP. CT
abdomen and pelvis ___ suggested gastroenteritis and gastric
distension. CRP elevated to 19.7 so likely aspect of
inflammation. We treated pain with Oxycodone 5mg Q4H:PRN
abdominal pain and nausea with reglan 5mg PO TID, and lorazepam
0.5 mg p.o. every 8 hours as needed given his prolonged QTC to
506 on admission. Frequency of his lorazepam was increased as
below.
# SUICIDAL IDEATION and
# SUBSTANCE ABUSE:
The patient was actively endorsing suicidal ideation with plans
to stop taking all medications and stop eating if discharged.
Psychiatric illness was interfering with medical recovery. He
was evaluated by the psychiatry team who recommended initiating
a ___ and transferring to inpatient psychiatric care, due
to concern for patient being a danger to himself. The patient's
history was noted for formerly documented cocaine, heroin, LSD,
use. Tox screen only positive for opiates and oxycodone, which
he was given in the ED. Collaboration with social work and
patient's father revealed that he was not safe to go home, given
that he had little to no social support. His father was not
amenable to having the patient live with him due to previous
aggressive and violent episodes. Patient had previously refused
a visiting nurse or voluntary admission to group programs for
further care. The patient was started on Seroquel 50 mg 3 times
daily, as well as Lorazepam 1 mg every 6 hours as needed for
anxiety.
# THROMBOCYTOPENIA: Likely in setting of cirrhosis. Baseline
platelets around ___ and platelets throughout admission
remained in this range. He had no active signs of bleeding.
# COAGULOPATHY with
# HISTORY OF FACTOR IX DEFICIENCY:
Pt had no signs of bleeding on this admission. INR elevated but
no vitamin K given as no signs of bleeding.
# HYPONATREMIA: 128-130, likely in setting of decompensated
cirrhosis. He had previously had fairly normal sodium levels
(during his last admission), which may be worsening for further
progression of his liver disease. Furthermore, sodium could
have been low due to diarrhea and hypovolemia. Improved over
admission, with improved Na at discharge.
# ASCITES and
# LOWER EXTREMITY SWELLING:
Pt with no prior TIPS, but has had previous ascites requiring
LVP (no prior episodes of SBP per Pt's outpatient
gastroenterologist, ___ @ ___. The patient had
ascites noted on his abdominal CT but did not feel distended and
there was no large pocket on bedside ultrasound. Therefore, no
large volume paracentesis was completed during his admission.
His diuretics were held initially in the setting of potential
infection, but resumed prior to discharge. To aid with fluid
balance, patient was actively diuresed with improved volume
status on discharge. He continued on his home diuretic regimen
at discharge.
CHRONIC/STABLE ISSUES:
# CIRRHOSIS: Due to primary sclerosing cholangitis. No evidence
of SBP. Previously grade I varices based on ___ EGD. Pt
reported some history of bleeding varices "when I was in high
school" which were banded, though Pt's primary
gastroenterologist ___ @ ___ has no record of
bleeding varices. Also with coagulopathy and stable
thrombocytopenia. On Carvedilol 6.25 mg PO Q12H. AFP negative in
___.
# ___ DISEASE:
Previously offered his medicines and did not take.
# NUTRITION:
We placed the patient on a low sodium diet
Transitional issues:
[] Please consider outpatient upper endoscopy for screening for
varices especially given evidence of portal hypertension
[] Please continue to assess social support, psychiatric illness
and substance abuse and patient's transplant candidacy
[] Needs weekly labs, including CBC, CHEM10, LFTs, ___.
Results should be faxed to the ___ at
___, (tel: ___
# CODE: Full code, confirmed
# CONTACT: Father/HCP, ___ (___)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 80 mg PO DAILY
2. Lactulose 30 mL PO TID:PRN constipation, confusion
3. Omeprazole 40 mg PO DAILY
4. Ranitidine 150 mg PO BID
5. Rifaximin 550 mg PO BID
6. Spironolactone 200 mg PO DAILY
7. Carvedilol 6.25 mg PO Q12H
8. Cyclobenzaprine 10 mg PO HS:PRN muscle spasms
9. Potassium Chloride Dose is Unknown PO DAILY
10. Magnesium Oxide Dose is Unknown PO ONCE
11. Zinc Sulfate 220 mg PO DAILY
12. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.rhamn
A
-
___
-
___
40-Bifido 3-S.thermop;<br>Lactobacillus
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) unknown oral
DAILY
13. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
Discharge Medications:
1. Docusate Sodium 100 mg PO BID:PRN constipation
2. LORazepam 1 mg PO Q6H:PRN Agitation, anxiety
RX *lorazepam [Ativan] 1 mg 1 tab by mouth every six (6) hours
Disp #*10 Tablet Refills:*0
3. QUEtiapine Fumarate 50 mg PO TID
4. Senna 17.2 mg PO QHS:PRN Constipation - First Line
5. Simethicone 40-80 mg PO QID:PRN gas pain, bloating
6. Lactulose 30 mL PO TID
7. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.rhamn
A
-
___
-
___
40-Bifido 3-S.thermop;<br>Lactobacillus
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 1 pill oral
DAILY
8. Carvedilol 6.25 mg PO Q12H
9. Furosemide 80 mg PO DAILY
10. Omeprazole 40 mg PO DAILY
11. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
12. Ranitidine 150 mg PO BID
13. Rifaximin 550 mg PO BID
14. Spironolactone 200 mg PO DAILY
15. Zinc Sulfate 220 mg PO DAILY
16. HELD- Potassium Chloride Dose is Unknown PO DAILY This
medication was held. Do not restart Potassium Chloride until you
have follow up labs to check your potassium levels
17.Outpatient Lab Work
K83.0
Needs weekly labs, including CBC, CHEM10, LFTs, ___. Results
should be faxed to the ___ at ___, (tel:
___ and patient's primary hepatologist, ___,
at ___ (tel: ___.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary diagnosis:
Community-acquired pneumonia
Hepatic encephalopathy
Secondary diagnsoses:
Thrombocytopenia
Hyponatremia
Substance abuse
Cirrhosis
___ disease
Suicidal Ideation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
WHY WAS I ADMITTED?
You were admitted because you are having abdominal pain, nausea,
vomiting, and confusion
WHAT WAS DONE WHILE I WAS HERE?
We treated you for pneumonia, and infection in your lungs
We gave you medication to decrease your confusion
We tested you for various stool, urine, and blood infections,
which were all negative
You were having thoughts of killing yourself by abstaining from
further medicines, and we believe your psychiatric illness was
interfering with your medical revovery. Therefore, it was
recommended that you be discharged to an inpatient psychiatric
unit.
WHAT SHOULD I DO NOW?
-You should take your medications as instructed
-You should go to your doctor's appointments as below
We wish you the best!
-Your ___ Care Team
Followup Instructions:
___
|
10145750-DS-12 | 10,145,750 | 27,421,018 | DS | 12 | 2176-05-20 00:00:00 | 2176-05-20 17:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal and back pain, pelvic mass
Major Surgical or Invasive Procedure:
Liver biopsy
History of Present Illness:
___ y.o female with no PMH who presented as a transfer from OSH
with a pelvic mass with concern for metastasis. Pt reports that
she was in her usual state of health up until about 2 weeks ago
when she was shoveling snow. She does not have a PCP nor has she
seen a doctor in ___ few years. She reported that ___ weeks ago
(pt reported about 2 weeks to writer) she was shoveling snow and
severe pain in her coccyx. Afterwards, she then developed
numbness and tingling in the perineal area. She then reported
constipation which she treated with miralax and then developed
fecal incontinence. She also developed difficulty initiating her
urine stream and urinary incontinence as as well. Pt also
reported that since her coccyx pain she has had bleeding from
her pelvic area which she cannot tell if it was from the rectum
or vagina although she reports using towels to absorb the blood.
Reports bleeding every 2 days. In terms of her pain, she reports
___ RlQ pain in the area of her mass and ___ in her coccyx
with radiation into her buttock pain is a "discomfort" She also
reports 1 episode of nausea and vomiting a few days ago. ___ also
has lost 20lbs unintentionally over the last year. Pt originally
evaluated at ___ and was found to have concern for metastatic
pelvic cancer. She was seen by the gyn onc service in the ___
ED who recommended medical oncology consultation as pt was not a
surgical candidate given presumed metastatic burden.
IN the ED, she was given zofran, dilaudid, IVF.
Other 10 ___ ros reviewed and negative for headache, dizziness,
St, URI, cP, sob, palpitations, abdominal pain, diarrhea,
melena, dysuria, joint pain, rash, other paresthesias or
weakness.
Past Medical History:
none
Social History:
___
Family History:
Denies fam hx of malignancy (specifically breast,
colon, ovarian, uterine, cervical). Denies fam hx of VTE. Fam
h/o
hypertension, T1DM
Physical Exam:
ADMISSION EXAM:
gen-well appearing, NAD
vitals-t 98.3, Bp 130/57, HR 66 RR 16 sat 97% on RA
HEENT-ncat eomi anicteric MMM
neck-supple, no JVD
chest-b/l ae no w/c/r
heart-s1s2 rr no m/r/g
abd-+bs, soft,+TTP RLQ no guarding or rebound
back-no spinal tenderness, +coccyx/lower sacral pain to deep
palpation
ext-no c/c/e 2+pulses
neuro-face symmetric, speech fluent, motor ___ x4, sensation
intact to LT
psych-calm, cooperative
DISCHARGE EXAM:
Vitals: 98.5 136/75 71 18 99 RA
Gen: NAD, well-appearing
HEENT: no scleral icterus
CV: rrr s1s2
Pulm: clear
Abd: soft, nt/nd +BS
GU: no foley in place
Ext: no edema
Neuro: alert and oriented x 3
psych: normal affect, pleasant
Pertinent Results:
ADMISSION:
___ 05:02AM LACTATE-1.1
___ 04:50AM ALT(SGPT)-18 AST(SGOT)-21 ALK PHOS-96 TOT
BILI-0.6
___ 04:50AM LIPASE-27
___ 04:50AM ALBUMIN-3.7
___ 04:50AM URINE HOURS-RANDOM
___ 04:50AM URINE HOURS-RANDOM
___ 04:50AM URINE UHOLD-HOLD
___ 04:50AM URINE GR HOLD-HOLD
___ 04:50AM WBC-9.4 RBC-4.37 HGB-11.9* HCT-35.2* MCV-81*
MCH-27.1 MCHC-33.7 RDW-14.2
___ 04:50AM NEUTS-76.1* LYMPHS-15.9* MONOS-6.6 EOS-1.2
BASOS-0.2
___ 04:50AM PLT COUNT-294
___ 04:50AM ___ PTT-27.6 ___
___ 04:50AM URINE COLOR-Yellow APPEAR-Clear SP
___
___ 04:50AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-SM
___ 04:50AM URINE RBC-49* WBC-34* BACTERIA-FEW YEAST-NONE
EPI-1
___ 04:50AM URINE HYALINE-5*
___ 04:50AM URINE MUCOUS-RARE
___ opinion wet read spinal MRI:
There is a 1.2 x 1.5 x 1.4 cm enhancing lesion within the right
S1 body
concerning for a metastatic lesion. A 9 mm enhancing focus
within the
posterior L5 vertebral body may also represent a metastatic
focus (3:17). A 2.2 x 2.2 cm right internal iliac enlarged lymph
node is partially visualized (04:31). There is no abnormal cord
signal or signs of canal narrowing.
___ opinion wet read pelvic MRI:
Irregular contour of the uterus with multiple masses including a
6.2 cm
enhancing mass in the lower uterine segment concerning for
malignancy, arising from the uterus versus cervix. There are
multiple enlarged lymph nodes in the pelvis including a 2.5 cm
right internal iliac lymph, 2.0 cm right external iliac lymph
node and a 1.9 cm left pelvic sidewall lymph node concerning for
metastatic spread. An enhancing focus in the sacrum is better
seen on the dedicated spine MR.
___ imaging:
___ CT abdomen/pelvis:
Impression:
1. Marked thickening and heterogeneity of the endometrium
with a
crescentic pocket of fluid in the uterine fundus highly
suspicious for endometrial carcinoma in the setting of
post-
menopausal bleeding and the presence of multiple necrotic
pelvic
wall lymph nodes and suspicion for distant metastatic
disease.
Additional differential includes leiomyosarcoma and
cervical
cancer though less likely.
2. Multiple pulmonary nodules the largest of which
measures 0.7
cm and a few which appear pleural-based, concerning for
metastatic disease. A dedicated chest CT is suggested for
complete evaluation.
3. Right sacroiliac sclerosis and punctate right femoral
sclerosis which may reflect benign etiology. However, in
the
presence of high suspicion for a primary malignancy,
metastatic
disease cannot be excluded.
4. Sigmoid diverticulosis without diverticulitis.
5. Cholelithiasis without cholecystitis.
pelvic u/s Impression:
1. Diffuse marked heterogeneity and thickening of the
endometrium highly suspicious for endometrial cancer given
the
patient's history of postmenopausal bleeding and presence
of
multiple hypoechoic foci throughout the liver. Differential
also
includes leiomyosarcoma with invasion of the adjacent
uterine
parenchyma. Cross-sectional imaging is suggested for
further
evaluation.
2. Normal vascular flow to both ovaries.
MRI pelvis/spine OSH:
Impression:
1. Metastatic disease with involvement of the osseous
structures,
epidural space at the level of the sacrum and
lymphadenopathy.
This likely arises from a gynecologic malignancy which
appears to
be centered on the cervix with extension into the uterus
and
posterior vaginal fornix. Endometrial carcinoma or uterine
sarcoma could have a similar appearance and should be
considered.
TIB/FIB XRAY ___:
1. No definite lytic or sclerotic lesion identified. MRI should
be considered for further evaluation if there is clinical
concern for malignancy.
2. Mild left knee osteoarthritis.
DISCHARGE EXAM:
___ 07:15AM BLOOD WBC-6.6 RBC-3.23* Hgb-9.0* Hct-25.8*
MCV-80* MCH-27.7 MCHC-34.7 RDW-13.9 Plt ___
___ 07:15AM BLOOD Glucose-123* UreaN-20 Creat-0.8 Na-139
K-4.6 Cl-103 HCO3-29 AnGap-12
___ 07:15AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.3
___ 11:03AM URINE Color-Yellow Appear-Hazy Sp ___
___ 11:03AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-MOD
___ 11:03AM URINE RBC-24* WBC-58* Bacteri-MANY Yeast-NONE
Epi-5 TransE-<1
___ 11:03AM URINE CastHy-2*
Brief Hospital Course:
HOSPITAL COURSE / Uterine-Cervical Cancer: ___ y.o woman with no
PMH who presented from OSH with metastatic appearing pelvic mass
with back pain and vaginal bleeding found to have metastatic
carcinoma originating from cervix or uterus. Imaging with
concern for metastasis to the spine, liver, and lungs. Oncology,
gyn oncology, radiation oncology were consulted. Pt underwent an
___ guided liver biopsy on ___ which revealed poorly
differentiated carcinoma originating from either the cervix or
uterus. Her pain was treated with PO and IV morphine. Her HCT
was monitored and she and her family were supported by SW. She
got first dose of carboplatin-paclitaxol on ___ with plan
for palliative radiation and chemotherapy as an outpatient. Seen
by gyn-onc and not thought to be a surgical candidate.
# back pain with perineal numbness/paresthesias: imaging was
concerning for osseous metastasis but no abnormal cord signals
seen on MRI. OSH imaging with concern for epidural sac
involvement but no evidence found here. Pain was controlled as
above. Spine surgery service was consulted who did not recommend
any surgical intervention. Neuro exam remained stable. Radiation
oncology recommended palliative radiation after chemo. Pain and
paresthesias were felt to be related to mass effect.
# UTI: had hematuria and dysuria. Urine culture grew GNRs in
OSH. Started on abctrim for 5 day course. Remained afebrile.
# L.tibial lesion - no specific lesion identified on XRAY. ___
consider MRI if persists.
HCP-Pt's ___ ___
TRANSITIONAL ISSUES:
- BEING DC-ED ON BACTRIM TO COMPLETE 5 DAY COURSE FOR UTI
- Needs appointments set up with radiation-oncology and medical
oncology.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Polyethylene Glycol 17 g PO BID:PRN constipation
2. Ibuprofen 400 mg PO Q8H:PRN pain
Discharge Medications:
1. Ondansetron 8 mg PO Q8H:PRN nausea from chemotherapy
RX *ondansetron 8 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*24 Tablet Refills:*1
2. Prochlorperazine ___ mg PO Q6H:PRN nausea from chemotherapy
RX *prochlorperazine maleate 5 mg ___ tablet(s) by mouth every
six (6) hours Disp #*120 Tablet Refills:*1
3. Lorazepam 0.5-1 mg PO Q6H:PRN nausea from chemotherapy
RX *lorazepam 0.5 mg ___ tab by mouth every six (6) hours Disp
#*120 Tablet Refills:*1
4. Polyethylene Glycol 17 g PO BID:PRN constipation
5. Morphine SR (MS ___ 30 mg PO Q12H
RX *morphine 30 mg 1 capsule(s) by mouth q12 Disp #*60 Capsule
Refills:*0
6. Morphine Sulfate ___ 15 mg PO Q4H:PRN severe pain
RX *morphine 15 mg 1 tablet(s) by mouth q4 Disp #*90 Tablet
Refills:*0
7. Sulfameth/Trimethoprim SS 1 TAB PO BID Duration: 3 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth q12 Disp #*8 Tablet Refills:*0
8. Omeprazole 20 mg PO BID
RX *omeprazole [Prilosec] 20 mg 1 capsule(s) by mouth twice a
day Disp #*60 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic carcinoma (cervix vs uterus)
Back pain
Vaginal bleeding/anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for further evaluation of a pelvic mass
concerning for metastatic cancer causing vaginal bleeding and
numbess and pain. For this you underwent a biopsy that revealed
that you had cancer originating from the uterus or cervix. You
were evaluated by the gynecology, oncology, radiation oncology,
spine surgery teams. You were started on pain medication for
your back pain. You recieved a dose of chemotherapy to reduce
the size of your tumor and will require outpatient treatment and
followup for continued management.
Followup Instructions:
___
|
10146033-DS-9 | 10,146,033 | 22,111,490 | DS | 9 | 2164-03-14 00:00:00 | 2164-03-16 13:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
indomethacin / Shellfish
Attending: ___.
Chief Complaint:
Fever and polyarticular joint pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with tophaceous gout, HTN and HLD who presents with 4 days
of worsening joint pain and fevers. He reports that his joint
pain has been worsneing over time for the past few months, but
notes that he has has worsening pain in his right shoulder,
knees and elbows for the the past ___ days. He reports feeling
warm at ___ but did not check his temperature. He was seen by
his rheumatologist on the day of admission and was noted to have
a fever to 103.3F. He reports that his last gout flare was less
than a month ago, but it did not involve as many joints. He is
currently only taking allopurinol for his gout, he had
previously been on colchicine which has recently been
discontinued and he has not taken this for his current symptoms.
He has also been taking tylenol #3 with mild relief of his pain.
Pain is currently ___ with movement in the above named joints
and "mild" at rest. He denies and recent alcohol use and has not
had any changes in his diet recently (no large meat containing
meals). Recent right knee tap showed WBC ___ RBCs, many
negatively birefringent needle-shaped xtals.
He reports constipation for the past ___ days, with no bowel
movement during this time frame (contraty to ED referral note,
which mentioned diarrhea - he currently denies diarrhea). Denies
abdominal pain.
In the ED, initial VS: 102.4 127 127/69 20 97%. He received
approximately 500cc of NS and 1g of Tylenol. BCx were sent and
he had a CXR and UA, as described below.
ROS: Denies chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
-Polyarticular tophaceous gout
-Hypertension
-Hyperlipidemia
-CKD (baseline Cr 1.1-1.4)
Social History:
___
Family History:
No reported gout or joint disease. Denies history of heart
disease, cancer or T2DM.
Physical Exam:
Admission exam:
VS - Temp 98.9F BP 125/82 HR 102 SpO2 97/RA
GENERAL - NAD, appears comfortable at rest
HEENT - NC/AT, PERRLA, EOMI
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, ___ systolic murmur at the LLSB
ABDOMEN - hypoactive BS, soft/NT, mildly distended
EXTREMITIES - Tophi in majority of fingers, on great toes
bilaterally and Achilles tendons bilaterally. Swelling of
bilateral shouders (R>L) with slight warmth, no erythema.
Non-tender swelling of olecranon bursae bilaterally, no warmth
or erythema. Swelling, mild erythema and warmth of left index
finger MCP. Swelling of knees bilaterally with no tenderness or
eryhtema, mild warmth. Good ROM in all joints except for passive
and active ROM limited in right shoulder and right knee ___ pain
and "tightness".
SKIN - no rashes or lesions, tophi as above
NEURO - awake, A&Ox3, CNs II-XII grossly intact, moving all
extremities, no focal defecits.
Discharge exam - unchanged from above, except as below:
ABDOMEN - normal BS, soft/NT/ND
Pertinent Results:
Admission labs:
___ 05:22PM BLOOD WBC-20.8* RBC-4.09* Hgb-10.9* Hct-33.5*
MCV-82 MCH-26.6* MCHC-32.4 RDW-17.4* Plt ___
___ 05:22PM BLOOD Neuts-92.5* Lymphs-4.0* Monos-2.8 Eos-0.6
Baso-0.1
___ 05:22PM BLOOD ___ PTT-26.5 ___
___ 05:22PM BLOOD Glucose-135* UreaN-14 Creat-1.4* Na-136
K-3.5 Cl-100 HCO3-24 AnGap-16
___ 05:28PM BLOOD Lactate-1.8
Discharge labs:
___ 08:20AM BLOOD WBC-16.4* RBC-3.89* Hgb-10.7* Hct-32.4*
MCV-83 MCH-27.5 MCHC-33.0 RDW-17.3* Plt ___
___ 08:20AM BLOOD ___ PTT-26.0 ___
___ 08:20AM BLOOD Glucose-161* UreaN-20 Creat-1.4* Na-138
K-3.5 Cl-102 HCO3-23 AnGap-17
___ 08:20AM BLOOD Calcium-9.2 Phos-2.8 Mg-1.9 Cholest-146
___ 08:20AM BLOOD Triglyc-86 HDL-50 CHOL/HD-2.9 LDLcalc-79
Imaging:
-CXR (___): No evidence of acute disease.
Brief Hospital Course:
___ with tophaceous gout, HTN and HLD who presents with fever
and pain/swelling in multiple joints
#Gout and polyarticular swelling/pain - Patient has severe
tophaceous gout which has been difficult to manage as an
outpatient. None of his joints appear to be septic, none are
erythematous or hot to the touch. He was seen by rheumatology
as an inpatient who felt this was consistent with a
polyarticular gout flare. Of note, he had not been taking
colchicine daily as he was prescribed during allopurinol
uptitration. He was restarted on this medication daily and was
started on a 12 day prednisone taper, starting at 40mg daily.
He was continued on allopurinol ___ daily. His pain was
managed with oxycodone during admission and had improved
somewhat during the course of his stay.
#Fever and leukocytosis - As mentioned above, no clearly septic
joint to explain these symptoms. He is not on steroids to
explain the leukocytosis. CXR clear at admission, UA not
suggestive of UTI and no other localizing signs of infection.
Blood cultures were obtained and were negative at the time of
discharge. He did not have any further fevers during this
admission and his leukocytosis improved modestly from 20 at
admission to 16 at discharge. He has been instructed to call
his PCP or return to the hospital with any further fevers.
#Constipation - Had mild abdominal distention at admission and
reported no bowel movements for ___ days. He was started on
senna/colace/bisacodyl and received colchicine as above. He had
a bowel movement prior to discharge and abdominal distention
improved. Calcium level was within normal limits.
#Elevated Cr - Appeared to be at baseline at the time of
admission, Cr also 1.4 in ___.
#HTN - Normotensive during this admission. He was kept on his
home doses of amlodipine and metoprolol.
#HLD - Simvastatin dose was decreased to 20mg daily given
interaction with amlodipine and colchicine, incresed risk for
rhabdo. Lipid panel was added on for outpatient providers and
was pending at time of discharge.
#Transitional issues:
-Discharged on prednisone taper
-Follow-up blood cultures and urine cultures, negative as or
discharge.
-Decreased simvastatin dose to 20mg daily because of interaction
with colchicine and amlodipine, lipid panel ordered but pending
at discharge, lipid control should be followed up as an
outpatient
-Has follow-up arranged with his rheumatologist
Medications on Admission:
-Tylenol ___ PO tid PRN pain
-Allopurinol ___ PO daily
-Amlodipine 10mg PO daily
-Colchicine 0.6mg PRN flare - rheum note mentions prescribing
this while uptitrating allopurinol, pt denies taking recently
-Metoprolol XL 25mg PO daily
-Omeprazole 20mg PO daily
-Simvastatin 40mg PO daily
Discharge Medications:
1. allopurinol ___ mg Tablet Sig: Five (5) Tablet PO DAILY
(Daily): Please take a total of 500mg allopurinol daily.
2. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
5. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. prednisone 5 mg Tablet Sig: Taper PO once a day: 8 tabs on
___, 7 tabs on ___, 6 tabs on, ___, 5 tabs on
___, 4 tabs on ___, 3 tabs on ___, 2 tabs on
___.
Disp:*70 Tablet(s)* Refills:*0*
8. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain for 7 days.
Disp:*12 Tablet(s)* Refills:*0*
9. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Polyarticular gout flare
Fever of unknown origin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your admission to
___ for fever and joint pain. We did not find any evidence of
any infection during your stay. We believe that your symptoms
were caused by a flare of your gout involving multiple joints.
It is important that you continue to take colchicine daily to
help prevent future gout flares. You will also take 12 days of
prednisone after discharge and follow-up with your
rheumatologist.
The following changes were made to your medications:
START colchicine 0.6mg by mouth daily
START prednisone taper, as outlined on medication list
START oxycodone 5mg by mouth every 6 hours as needed for pain
CHANGE simvastatin 20mg by mouth daily
Followup Instructions:
___
|
10146186-DS-13 | 10,146,186 | 27,138,521 | DS | 13 | 2120-04-21 00:00:00 | 2120-04-22 22:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / Losartan
Attending: ___
Chief Complaint:
muscle pain, dark urine
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This patient is a ___ year old male who complains of
fatigue/malaise. Pt presentsfrom home via ambulance with
complaints of fatigue, malaise, ___ "body/muscle pain" and
unable to ambulate without shuffling. Pt state he has brown
urine today. Patient states has diffuse muscle aches and
weakness which gradually worsened since ___. The patient has
a history of spinal stenosis treated with Oxycodone and
Methadone. he denies any new back pain, no trauma. No recent
illness/F/C. No drug abuse (although tox screen positive for
benzos, cannabis). No new medications (except Losartan 2 months
ago). No rash, no joint swelling. +dark brown urine today. Went
to ___.
In ___, labs were notable for Creatinine 1.4, normal serum
K+, wbc of 12 and serum CK >20K. Has history of previous
prolonged QT on EKG, and was >500 in ___. Treated with IVF,
bicarb. UA also with bacteria/nitrite. Did not get abx prior to
transfer.
In the ___ intial vitals were: 10 98. 74 177/103 18 99%. Urine
was sent for cultures. Patietn was in extreme pain and BP came
down with IV dilaudid. Was given ceftriaxone and transferred to
med for further mx.
On the floor, patient continues to be in pain. does not report
any urinary symptoms or trying any drugs other those prescribed
and cannabis.
Review of Systems:
(+) PER HPI
Past Medical History:
CERVICAL DISC DISEASE
HYPERTENSION - ESSENTIAL
Sciatica
SPINAL STENOSIS, UNSPEC SITE
HEPATITIS - C, CHRONIC
Pain syndrome, chronic
Adjustment Disorder with Depressed Mood
Long QT
Social History:
___
Family History:
no hx of rhabdo or myositis, father with CAD
Physical Exam:
Exam on Admission:
Vitals- 98.5 176/98 79 18 99 ra
General- Alert, oriented, uncomfortable
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
Exam on Discharge:
Vitals- 98.1 172/112 70 18 98%RA
8hrs: I:not recorded O: 600
24hrs: I: 3200 O: 6150
General- Alert, oriented, comfortable, NAD
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated
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, nondistended, normoactive bowel
sounds Ext- warm, well perfused, 2+ pulses
Neuro- CNs2-12 intact, sensation normal, 4+/5 strength bilateral
lower extremities
Pertinent Results:
Labs on Admission:
___ 09:20AM PLT COUNT-142*
___ 09:20AM WBC-10.2 RBC-3.73* HGB-12.6* HCT-38.1*
MCV-102* MCH-33.8* MCHC-33.2 RDW-12.1
___ 09:20AM CALCIUM-7.6* PHOSPHATE-3.6 MAGNESIUM-2.0
___ 09:20AM ___
___ 09:20AM GLUCOSE-147* UREA N-33* CREAT-1.4* SODIUM-138
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-25 ANION GAP-16
___ 10:30AM CALCIUM-7.6* PHOSPHATE-3.7 MAGNESIUM-2.0
___ 10:30AM ___
___ 10:30AM GLUCOSE-104* UREA N-34* CREAT-1.5* SODIUM-138
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-29 ANION GAP-13
Interval labs:
___ 06:20AM BLOOD Glucose-97 UreaN-25* Creat-1.5* Na-140
K-3.2* Cl-107 HCO3-25 AnGap-11
___ 05:30PM BLOOD Glucose-115* UreaN-23* Creat-1.7* Na-141
K-3.6 Cl-108 HCO3-20* AnGap-17
___ 11:30AM BLOOD ALT-684* AST-2315* ___
AlkPhos-57 TotBili-0.7
___ 06:25AM BLOOD CK(CPK)-8256*
___ 06:15AM BLOOD CK(CPK)-4063*
___ 06:20AM BLOOD CK(CPK)-2050*
___ 11:30AM BLOOD CK-MB->500 cTropnT-0.13*
___ 06:20AM BLOOD CK-MB-297* MB Indx-1.3 cTropnT-0.18*
___ 01:00PM BLOOD CK-MB-266* cTropnT-0.17*
___ 06:25AM BLOOD CK-MB-110* MB Indx-1.3 cTropnT-0.18*
___ 11:30AM BLOOD TSH-1.0
Discharge Labs:
___ 06:15AM BLOOD WBC-8.1 RBC-3.28* Hgb-11.1* Hct-33.5*
MCV-102* MCH-33.8* MCHC-33.1 RDW-12.4 Plt ___
___ 06:45AM BLOOD Glucose-102* UreaN-24* Creat-1.7* Na-142
K-3.5 Cl-110* HCO3-22 AnGap-14
___ 06:45AM BLOOD CK(CPK)-1410*
___ 06:45AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.6
Imaging:
Renal Ultrasound ___
Final Report
HISTORY: Hypertension and chronic back pain coming in
rhabdomyolysis.
Worsening renal function
COMPARISON: None
TECHNIQUE: Grayscale and Doppler and spectral imaging of the
kidneys
FINDINGS:
The right kidney measures 10.2 cm and the left kidney measures
10.8 cm.
Neither shows evidence of hydronephrosis, renal stones or solid
renal masses. The bladder is unremarkable.
DOPPLER ULTRASONOGRAPHY: The main and intrarenal arteries are
patent
bilaterally. The resistive indices on the right in the upper,
mid and lower poles are 0.66, 0.69 and 0.69 respectively. On
the left, the resistive indices in the upper, mid, lower polar
0.63, 0.65 and 0.69. Note is made of delayed acceleration times
in bilateral main renal arteries.
IMPRESSION:
1) No hydronephrosis.
2) Delayed arterial acceleration bilaterally in a symmetric
fashion. If
further evaluation is desired, can consider CTA or MRA to
evaluate for
stenosis.
The study and the report were reviewed by the staff radiologist.
KUB ___
Final Report
HISTORY: History of rhabdomyolysis now with acute diffuse
abdominal pain and no bowel movement for several days.
COMPARISON: None available.
FINDINGS:
One frontal and one left lateral decubitus view of the abdomen
shows gaseous distention of the transverse colon in the region
of the splenic flexure. There are no dilated loops of small
bowel to suggest obstruction. There is no free air on left
lateral decubitus view or pneumatosis. There is hardware in
place in the lumbar spine.
IMPRESSION:
Gaseous distention of the transverse colon. No dilated loops of
small bowel to suggest obstruction or ileus. No evidence of free
air.
Brief Hospital Course:
Mr. ___ is a ___ M with severe muscle pain and ___ in the
setting of elevated CK suggesting rhabdomyolysis with unclear
precipitating factor.
Active Issues:
# Rhabdomyolysis: On presentation to ___>20k, on
admission here ___. ___ (unclear baseline but years ago
creatinine was 1.1-1.3, 1.4 on admission). Etiology considered
included drug induced as Methadone can cause rhabdo, or Losartan
(<1% chance of causing rhabdo as an adverse reaction). Did not
seem that patient had over exerted himself in last week given
baseline chronic pain and disability. However, he did report
having helped his brother get a new truck during which he
thought he injured his back. He reports taking more of his pain
medications than usual and not getting out of bed for several
days. In the setting of immobilization, narcotic use and ETOH
use, this is the most likely cause of the patient's severe
rhabdomyolysis. He denied any recent illness. Utox negative
for cocaine. No electrolyte abnormalities on admission. No
recent trauma.
The patient was aggressively hydrated on arrival with goal UOP
of 200-300 cc/hr which patient met. His CK was trended and
decreased significantly with aggressive hydration. His lytes
were monitored and repleted. Losartan and Atenolol were held
for concern that those medications would further contribute to
his ___. Patient's pain was controlled with his home Methadone
and initially with IV Dilaudid. As pain improved, patient was
transitioned back to home oral medications. Patient initially
had foley catheter which was placed for urine output monitoring
as well as for patient safety given degree of muscle injury and
pain he was experiencing. After Foley was removed, patient's
creatinine rose to 1.7. The Renal service was consulted for
concern of worsening ATN. Patient endorsed some post renal
obstructive symptoms with incomplete voiding. Urine sediment
examination was not c/w acute ATN and it was thought that
patient's rise in creatinine was a post-renal obstructive
process. He had PVRs of 250-350cc. He was started on Tamsulosin.
Renal U/S showed no hydronephrosis but did show delayed arterial
acceleration bilaterally. It was recommended that he have follow
up imaging to assess for RAS after his renal function improves.
The patient was additionally seen and evaluated by physical
therapy for concern of significant deconditioning from this
acute disease process. It was recommended that patient undergo
home ___ for one week post discharge. Patient was educated on
signs and symptoms of rhabdomyolysis and instructed to return to
the ___ if these symptoms were to recur.
# Chest Pressure: Patient developed some chest pressure this
admission, initially lasting about one hour, felt like a 2lb
weight on his chest without any associated symptoms of
diaphoresis, N/V, or radiation of the pain. He denied having
experienced this previously. His symptoms resolved
spontaneously but cardiac enzymes were trended which showed
Troponin T 0.13--> 0.18--> 0.17--> 0.18 with flat MB index, and
in setting of worsening ___ and ___ dynamic EKG changes was
attributed to skeletal muscle breakdown. Initial EKG at ___
showed significantly prolonged QTc which shortened over duration
of admission. He had lateral ST segment depressions which
remained stable.
# Abdominal pain: Patient developed abdominal pain in setting of
constipation. Patient had been refusing bowel regimen for fear
of fecal incontinence but ultimately constipation and pain
resolved with use of an enema. Encouraged patient to take stool
softeners at home if continuing to be on Methadone/Oxycodone
long term.
# HTN: was hypertensive in ___ but initially improved with pain
control. Atenolol and Losartan held as above and patient was
started on Metoprolol and Hydralazine. Pressures were still
elevated and somewhat difficult to control. Patient was
ultimately transitioned to Labetalol 200mg BID. Unclear if
renal artery stenosis is contributing factor in patient's
worsening HTN. Does need further work up as outpatient with
# PAIN: patient has baseline chronic back pain. Continued home
methadone (initially attempted 10% taper in case this was a
contributing cause of his rhabdo, ultimately patient was
discharged on home dose) and continued on his home oxycodone.
# ETOH intake: patient reports drinking 6pack/day. ___ have
contributed to this episode of rhabdomyolysis but he denied any
recent increase in ETOH intake. Patient was placed on CIWA scale
initially but there was no evidence of any withdrawal symptoms.
Transitional Issues:
# F/u renal function as outpatient, check CK
# Patient will need CTA or MRA to evaluate for RAS once renal
function is back to baseline
# ___ need further titration of blood pressure meds as
outpatient, would avoid ACEI and ___ in this patient
# Patient was seen and evaluated by ___ and recommendation for
home ___ given severity of patient's illness
# Consider tapering patient off Methadone as unclear if it was
contributing factor in patient's presentation
# Questionable history of hepatitis C with ongoing ETOH use,
would further assess liver function in less acute setting
# Code: Full (discussed with patient)
# Emergency Contact: Sister ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN pain
2. Methadone 40 mg PO TID
3. Losartan Potassium 25 mg PO DAILY
4. Atenolol 25 mg PO DAILY
Discharge Medications:
1. Methadone 40 mg PO TID
2. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN pain
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. Senna 1 TAB PO BID constipaion
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*60 Capsule Refills:*0
5. Tamsulosin 0.4 mg PO HS
RX *tamsulosin 0.4 mg 1 capsule,extended release 24hr(s) by
mouth at bedtime Disp #*30 Capsule Refills:*0
6. Labetalol 200 mg PO BID
RX *labetalol 200 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Rhabdomyolysis
Secondary: HTN
Secondary: Chronic pain
Secondary: Post-renal obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care while you were
admitted to ___. You were admitted to the hospital after you
developed bad muscle aches and dark urine. You were found to
have significant muscle breakdown, called Rhabdomyolysis. You
were given lots of intravenous fluids to hydrate you and help
get rid of muscle breakdown products. During your stay you were
seen by the kidney doctors to further ___ your kidney
function. You told us about some symptoms concerning for
urinary obstruction and we started a medication called
Tamsulosin to help with this. We also are referring you to a
Urologist who can better help with this problem, please try to
make the appointment listed below. Your blood pressure was very
high while you were here and we discontinued your home
medications as they may have been contributing to your kidney
injury. We started a new medication called Labetalol which you
should take twice a day. Please follow up with the appointments
as listed below. We wish you well.
Followup Instructions:
___
|
10146602-DS-22 | 10,146,602 | 27,939,683 | DS | 22 | 2185-01-15 00:00:00 | 2185-01-15 12:47:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Avodart / Glucocorticoids (Corticosteroids)
Attending: ___.
Chief Complaint:
fever/L hand numbness
Major Surgical or Invasive Procedure:
Recent:Coronary artery bypass grafting x4, with the left
internal mammary artery to left anterior descending artery,
reverse saphenous vein graft to the posterior descending
artery, the mid branch of the circumflex artery, and the
first diagonal artery.
/p Cystoscopy, bilateral ureteral stent placement, ___
s/p Exploratory laparoscopy, drainage of pelvic fluid
collection,
lysis of adhesions and creation of diverting loop ileostomy,
___
s/p Flexible sigmoidoscopy with directed therapy to the fistula
tract with injection of Surgiflo glue, ___
s/p Laparotomy, extensive lysis of adhesions, oversew serosal
disruption x2, and excision of ileal mucocele, ___
s/p Laparotomy, lysis of adhesions in preparation for ventral
hernia repair, ___
s/p Laparoscopic sigmoid colectomy with takedown of splenic
flexure, ___
s/p Lipoma Excisions, multiple
s/p Medialization laryngoplasty, left and right, Gore-Tex, ___
s/p Orchiectomy, left
s/p Redo bilateral component separation; internal corset of
polypropylene mesh deep to the external oblique, ___
s/p Takedown ileostomy with ileoileostomy anastomosis, ___
s/p VATS right upper lobe wedge and mediastinal lymph node
dissection, ___
s/p Ventral hernia repair and panniculectomy, ___
s/p Sinus Surgery
s/p Tongue Surgery
s/p Skin Grafting left thigh related to Bowens Disease
s/p left subclavian port-a-cath
History of Present Illness:
Dr. ___ is a ___ gentleman with
h/o adrenal insufficiency on prednisione and HIV who is now POD
8
from CABG. His postop course was complicated by hypotension
requiring prbc transfusion and increased pain in his vein
harvest
leg with ___ negative for DVT. He was discharged to home
yesterday and felt well on his initial time at home. He
developed
brief chills and temp 101 last evening. He denies cough,
dysuria,
abdominal pain, nausea or vomiting. He had been complaining of L
sided back pain for several days and developed L had numbness
this evening, initially in his ___ and ___ fingers and now in
his
___ finger as well.
Past Medical History:
- Lung cancer (well differentiated adenocarcinoma, s/p VATS RUL
wedge resection and mediastinal LND ___
- HIV
- Hepatitis B infection
- History of pulmonary embolism
- Adrenal insufficiency
- Diabetes
- HLD
- Osteoporosis
- Chronic kidney disease
- COPD
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Exam:
Pulse:95 Resp:14 O2 sat:98% on 2L
B/P Right:93/57
General:well appearing, tired, in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRL [] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Softly distended [x] non-tender [x] hypoactive bowel
sounds +[x]
Extremities: Warm [x], delayed capillary refill in bilat hands
Edema [x]2+ _____
sternal incision healing well, no erythema or drainage
L leg vein harvest incision with 2cm erythema, no drainage, not
warm, no fluid collection
Neuro: Grossly intact [x] hand strength equal bilaterally
Pulses:
DP Right:+ Left:+
___ Right: + Left:+
Radial Right:+ Left:+
Discharge Exam:
VS: T HR BP RR O2sat
Gen: no acute distress
Neuro: alert and oriented x3, continues to complain of tingling
in left ulnar distribution
CV: regular rate and rhythm, no murmur. Sternum stable-inciswion
clean dry and intact
Pulm:clear to auscultation bilaterally
Abdm: soft, nontender, non distended, + bowel sounds
Ext: warm and well perfused, 1+ bilat lower extremity edema.
left EVH site clean, dry, and intact
Pertinent Results:
Admission Labs:
___ 01:03AM PLT COUNT-239
___ 01:03AM WBC-5.0 RBC-2.72* HGB-7.8* HCT-24.8* MCV-91
MCH-28.7 MCHC-31.5* RDW-16.2* RDWSD-52.7*
___ 01:03AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 01:03AM ALBUMIN-3.3* CALCIUM-8.9 PHOSPHATE-2.4*
MAGNESIUM-1.9
___ 01:03AM cTropnT-0.07*
___ 01:03AM ALT(SGPT)-25 AST(SGOT)-43* ALK PHOS-29* TOT
BILI-0.5
___ 01:03AM GLUCOSE-97 UREA N-31* CREAT-2.0* SODIUM-137
POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-26 ANION GAP-20
___ 01:09AM LACTATE-2.4*
___ 03:20AM URINE RBC-0 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 03:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 03:20AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:20AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS*
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 11:15AM TSH-3.2
___ 11:15AM %HbA1c-7.3* eAG-163*
Discharge Labs:
___ 05:56AM BLOOD WBC-3.3* RBC-2.56* Hgb-7.3* Hct-23.7*
MCV-93 MCH-28.5 MCHC-30.8* RDW-16.3* RDWSD-54.4* Plt ___
___ 05:56AM BLOOD Plt ___
___ 05:56AM BLOOD Glucose-99 UreaN-21* Creat-1.5* Na-138
K-3.7 Cl-101 HCO3-24 AnGap-17
___ 05:56AM BLOOD Phos-2.5* Mg-2.3
___ MRI
There is no intra or extra-axial mass, acute hemorrhage or
infarct. The sulci, ventricles and cisterns are within expected
limits for the patient's age. The major intracranial flow voids
are preserved. There is mild mucosal thickening of the ethmoid
air cells. The remainder the paranasal sinuses are clear. The
orbits are unremarkable. The mastoid air cells appear clear.
IMPRESSION:
1. No acute infarct or intracranial hemorrhage.
CT scan ___
CT head without contrast:
No evidence of acute large territorial infarct or hemorrhage
CTA head and neck:
Examination is mildly degraded due to motion. There is no large
aneurysm,
definite dissection, or evidence of vascular occlusion.
Irregularity and
narrowing of the common carotid arteries, particularly the
bifurcation is
consistent with atherosclerosis.
Small mediastinal air and fluid compatible with patient's recent
history of CABG.
___ Soft tissue lower extremity US
Subcutaneous edema surrounding the surgical incision in the left
calf, which could be seen in the setting of cellulitis, but no
organized fluid collection identified to suggest abscess.
___ LENIS
1. Stable appearance of a nonocclusive thrombus in the left
distal superficial femoral vein. No evidence of propagation or
new DVT bilaterally.
2. Calf edema of the right lower extremity. Please refer to
separately
dictated report of same date for ultrasound of the venous
harvest site.
Radiology Report CHEST (PA & LAT) Study Date of ___ 1:19
AM
Final Report:
There has been interval resolution of the right-sided pleural
effusion. The left-sided pleural effusion persistent. The
cardiomediastinal silhouette is similar to the prior examination
in this patient status post recent CABG and more remote partial
resection of the right lung. Midline sternal wires are well
aligned and intact. Mediastinal clips are noted. No definite
focal consolidation is identified. Multifocal subsegmental
atelectasis has slightly decreased in the interval.
IMPRESSION:
No definite focal consolidation identified.
___, MD
___, MD electronically signed on WED ___
8:26 AM
Brief Hospital Course:
Patient was admitted for evaluation of fevers and left finger
numbness. He underwent extensive work-up. CT and MRI were
negative. Seen by Neurology, and it was determined that the
source of his finger numbness was related to Ulnar compressive
neuropathy. The numbness has largely resolved, and they
recommended a brace if the numbness should return. He still c/o
left upper muscularskeletal back pain, that is well managed with
a lidocaine patch and warm pack. His creatinine was 2.0 on
admission, and has slowly improved. He was febrile on admission,
seen by the ID department, started on ceftazidime and
vancomycin due to past medical issues and the concern for
infection. He had gram negative rods in the urine, however
infectious disease did not feel it needed to be treated. His
soft tissue ultrasound was negative for infection. He continues
to have a small superficial femoral vein non occlusive clot that
was unchanged from prior examination. Patient remained
hemodynamically stable. His evening lantus was also resumed. In
light of his progress, he was deemed safe for discharge to home
on HD 3.
Medications on Admission:
Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
Aspirin EC 81 mg PO DAILY
Atorvastatin 40 mg PO QPM
Docusate Sodium 100 mg PO BID
Fluticasone Propionate NASAL 1 SPRY NU BID
Furosemide 20 mg PO DAILY
Gabapentin 100 mg PO TID
Genvoya (elviteg-cobi-emtric-tenofo ala) ___ mg oral
DAILY
Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN dyspnea
Januvia (SITagliptin) 25 mg oral DAILY
MetFORMIN (Glucophage) 500 mg PO BID
Metoprolol Tartrate 75 mg PO TID
OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain:
moderate/severe
Pantoprazole 40 mg PO Q24H
Potassium Chloride 10 mEq PO DAILY Duration: 7 Days
RX *potassium chloride 10 mEq 1 capsule(s) by mouth daily
PredniSONE 5 mg PO DAILY
Raltegravir 400 mg PO BID
Tiotropium Bromide 1 CAP IH DAILY
TraMADol 50 mg PO Q4H:PRN Pain - Moderate
Discharge Medications:
1. Fluticasone Propionate NASAL 1 SPRY NU BID
2. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % to left shoulder once a day Disp #*30 Patch
Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
4. Potassium Chloride 20 mEq PO DAILY Duration: 10 Days
RX *potassium chloride 20 mEq 1 tablet(s) by mouth once a day
Disp #*10 Tablet Refills:*0
5. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
6. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
7. Aspirin EC 81 mg PO DAILY
8. Atorvastatin 40 mg PO QPM
9. Docusate Sodium 100 mg PO BID
10. Furosemide 20 mg PO DAILY Duration: 5 Days (total 10
days-has 5 days at home now) RX *furosemide 20 mg 1 tablet(s) by
mouth once a day Disp #*5 Tablet
11. Gabapentin 100 mg PO TID
12. Genvoya (elviteg-cobi-emtric-tenofo ala) ___ mg
oral DAILY
13. Glargine 10 Units Bedtime
14. Metoprolol Tartrate 25 mg PO BID
15. Pantoprazole 40 mg PO Q24H
16. PredniSONE 5 mg PO DAILY
17. Raltegravir 400 mg PO BID
18. Tiotropium Bromide 1 CAP IH DAILY
19. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Fever of unknown origin
Ulnar compressive neuropathy, now resolved
Secondary:
Coronary artery Disease s/p CABGx4 (LIMA> LAD, SVG> PDA, Cx, D1)
PMHx: Adrenal Insufficiency, on steroids,- Bowen's disease - CIS
rectum, s/p surgery ___ In Situ frenulum of penis,
Chronic Kidney Disease (baseline Cre 1.3-1.5), Chronic
Obstructive Pulmonary Disease, Diabetes Mellitus Type II,
Diverticulitis, Hepatitis B, HIV, Hypertension, Pulmonary
Embolism ___, Lung Adenocarcinoma s/p VATS, Osteoporosis,
Squamous Cell Carcinoma of Tongue, surgery ___, Testicular
Torsion s/p left orchiectomy, Ventral Hernia,GERD, BPH, History
of Kidney Stones s/p lithotripsy, Left metatarsal fracture,
PSHx: s/p Cystoscopy, bilateral ureteral stent placement, ___
s/p Exploratory laparoscopy, drainage of pelvic fluid
collection,
lysis of adhesions and creation of diverting loop ileostomy,
___
s/p Flexible sigmoidoscopy with directed therapy to the fistula
tract with injection of Surgiflo glue, ___ s/p Laparotomy,
extensive lysis of adhesions, oversew serosal disruption x2, and
excision of ileal mucocele, ___, s/p Laparotomy, lysis of
adhesions in preparation for ventral hernia repair, ___, s/p
Laparoscopic sigmoid colectomy with takedown of splenic flexure,
___, s/p Lipoma Excisions, multiple, s/p Medialization
laryngoplasty, left and right, Gore-Tex, ___, s/p Orchiectomy,
left, s/p Redo bilateral component separation; internal corset
of polypropylene mesh deep to the external oblique, ___, s/p
Takedown ileostomy with ileoileostomy anastomosis, ___, s/p
VATS right upper lobe wedge and mediastinal lymph node
dissection, ___, s/p Ventral hernia repair and panniculectomy,
___, s/p Sinus Surgery, s/p Tongue Surgery, s/p Skin Grafting
left thigh related to Bowens Disease, s/p left subclavian
port-a-cath
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tramadol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema 1+ pedal edema bilaterally
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage.
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon-when you will
be able to drive
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10146735-DS-14 | 10,146,735 | 27,669,890 | DS | 14 | 2136-08-08 00:00:00 | 2136-08-09 17:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Keflex
Attending: ___.
Chief Complaint:
nausea/vomiting/seizure
Major Surgical or Invasive Procedure:
___ repair of umbilical hernia w/o mesh
___ paracentesis
___ paracentesis
___ paracentesis
___ paracentesis
History of Present Illness:
___ is a ___ y/o M with EtOh cirrhosis ___
Class C; with decompensations including variceal bleed, hepatic
encephalopathy, and refractory ascites), anxiety, and past
opiate abuse, who was referred in to ___ on ___ for
vomiting x 7 days and leakage of large amounts of peritoneal
fluid from his umbilical hernia. He also had nausea and vomiting
of light brown non-bloody fluid x 7 days, up to 3x/daily. Prior
to admission, his umbilical hernia "sprung a leak" one day after
the ___ LVP, and on ___ he presented to ___
___, where they used dermabond to control his leakage. He
states that his fluid was "coming out in buckets". He was
discharged from ___ on ___. He then presented
to his regularly scheduled paracentesis appointment on ___,
however they were unable to find a large enough pocket to drain.
In the ED at ___ due to his abdominal pain, a KUB was obtained
showing "Multiple dilated small bowel loops in the central
abdomen, suggesting small bowel obstruction." The patient was
admitted to the ___ team and a CT abdomen was obtained
showing "Small bowel containing umbilical hernia and findings
consistent with small bowel obstruction, with transition point
at the hernia neck. Findings are concerning for entrapped small
bowel in the umbilical hernia, causing small bowel obstruction."
Due to ongoing symptoms he went on ___ to the surgery
service and to the OR for a repair of his umbilical hernia w/o
mesh. After his repair he remained intubated in the TSICU.
On ___ he had his NG tube and foley removed and was
extubated. He went to ___ for paracentesis. In ___, per the staff,
he was noted to have tonic-clonic eye deviation (upward-right)
with lip smacking, movement of all 4 limbs, and unresponsiveness
for ___ minutes. Following this he was more confused than his
baseline. On ___ he had a 3L paracentesis, negative for SBP.
Albumin was given and antibiotics were all stopped. His keppra
was stopped per neuro recs and MRI brain was ordered. On
___ early AM transferred to ___ and overnight had some
nausea, but otherwise no acute events. Patient transferred to
hepatology for ongoing management of severe ascites and
hyponatremia (Lasix stopped due to this).
At time of transfer, patient's vitals:
98.2 99 / 63 80 18 94 RA
Patient noted +flatus, +significant abdominal pain, no passing
of BMs, +poor appetite, denies shortness of breath or chest
pain.
ROS:
(+) per HPI
Past Medical History:
1.Chronic cirrhosis alcoholic, with associated ascites and
encephalopathy; grade 2 esophageal varices & portal gastropathy
on EGD in ___.
2. Previous opiate abuse on suboxone, no suboxone since several
months ago
3. Tobacco abuse
4. Anxiety
5. History of hyperplastic colonic polyp
Social History:
___
Family History:
Father died of cardiac disease, mother was alcoholic
Physical Exam:
ADMISSION EXAM:
================================
VS: 98.2 99 / 63 80 18 94 RA
Weight: 58.97kg
I/O: not recorded
GENERAL: Cachectic male, uncomfortable appearing w/temporal
wasting.
HEENT: normocephalic, atraumatic, no conjunctival pallor but
mild scleral icterus, EOMI, OP clear.
NECK: Supple, JVP flat.
HEART: RRR, normal S1/S2, no murmurs rubs or gallops.
LUNGS: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Abdominal binder in place from hernia surgery,
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
DISCHARGE EXAM:
================================
VS:98.2 PO 103/64 84 16 97 97
I/Os: 2857/75+4void +5BM(24hr);834/700(8hr)
WEIGHT:
65.86<-70.85<-68.13<-66.41<-64.68<-62.3<-63.71<-<-60.5<-60.1 kg
GENERAL: Cachectic male w/temporal wasting. AAOx3, interactive,
appropriate
HEENT: normocephalic, atraumatic, mild icterus, EOMI.
NECK: Supple, JVP flat.
HEART: RRR, normal S1/S2, no murmurs rubs or gallops.
LUNGS: faint bibasilar crackles otherwise CTAB
ABDOMEN: soft, moderately distended, nontender to palpation,
+BS. Groin mildly distended, nontender to palpation
EXTREMITIES: Warm, well-perfused, no cyanosis or clubbing. no
edema.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout. No asterixis
Pertinent Results:
ADMISSION LABS:
================================
___ 12:00PM BLOOD WBC-14.9*# RBC-3.64* Hgb-10.6* Hct-32.3*
MCV-89 MCH-29.1 MCHC-32.8 RDW-18.9* RDWSD-60.3* Plt ___
___ 12:00PM BLOOD Neuts-78.5* Lymphs-11.9* Monos-8.5
Eos-0.1* Baso-0.3 Im ___ AbsNeut-11.70*# AbsLymp-1.77
AbsMono-1.27* AbsEos-0.02* AbsBaso-0.04
___ 12:00PM BLOOD ___ PTT-28.9 ___
___ 12:00PM BLOOD Glucose-114* UreaN-34* Creat-2.1*#
Na-126* K-4.0 Cl-74* HCO3-33* AnGap-23*
___ 12:00PM BLOOD ALT-14 AST-57* AlkPhos-197* TotBili-2.8*
___ 12:00PM BLOOD Albumin-2.9*
___ 08:00AM BLOOD Albumin-3.8 Calcium-8.6 Phos-3.8 Mg-1.8
___ 02:36PM BLOOD Lactate-2.3*
OTHER LABS:
================================
___ 03:55PM BLOOD calTIBC-108* VitB12-1123* Folate-17
Ferritn-35 TRF-83*
___ 03:55PM BLOOD TSH-1.8
PERITONEAL FLUID:
___ 04:47PM ASCITES WBC-118* RBC-2400* Polys-4* Lymphs-65*
Monos-1* Mesothe-1* Macroph-29*
___ 04:47PM ASCITES TotPro-2.3 LD(LDH)-60 Albumin-1.4
___ 09:44AM ASCITES WBC-422* RBC-3825* Polys-4* Lymphs-61*
___ Macroph-35*
___ 09:44AM ASCITES TotPro-3.4 Glucose-180 LD(___)-74
Albumin-2.4
___ 02:08PM ASCITES WBC-975* ___ Polys-37*
Lymphs-21* Monos-20* Mesothe-4* Macroph-18*
___ 02:08PM ASCITES TotPro-4.0 LD(___)-111 Albumin-2.9
___ 01:57PM ASCITES WBC-759* ___ Polys-20*
Lymphs-22* Monos-0 Plasma-2* Mesothe-5* Macroph-51*
___ 01:57PM ASCITES TotPro-3.0 LD(LDH)-104 Albumin-2.4
___ 02:47PM ASCITES WBC-200* ___ Polys-24*
Lymphs-24* Monos-15* Mesothe-4* Macroph-33*
___ 09:12AM ASCITES WBC-278* ___ Polys-15*
Lymphs-75* Monos-2* Basos-1* Mesothe-5* Macroph-2* Other-0
MICROBIOLOGY:
================================
Blood cultures ___: no growth
Urine cultures ___: no growth
Urine culture ___: YEAST. 10,000-100,000 CFU/mL.
PERITONEAL FLUID:
___ 9:12 am PERITONEAL FLUID
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 2:47 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 1:57 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 2:08 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 9:44 am PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Time Taken Not Noted Log-In Date/Time: ___ 4:48 pm
PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
___ 10:51 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay.
___ 4:48 pm
PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ 8:01 pm URINE Source: ___.
URINE CULTURE (Pending):
IMAGING/STUDIES:
================================
___ CT A/P:
1. Small bowel containing umbilical hernia and findings
consistent with small bowel obstruction, with transition point
at the hernia neck. Findings are concerning for entrapped small
bowel in the umbilical hernia, causing small bowel obstruction.
2. Liver cirrhosis with small to moderate ascites.
3. Large left hydrocele.
4. Left inguinal hernia contains a small portion of anterior
bladder wall.
5. Colonic diverticulosis.
___ CXR: IMPRESSION: No acute findings.
___ ECG:
Sinus rhythm. Left atrial abnormality. Atrial premature beats.
Non-specific intraventricular conduction delay. Compared to the
previous tracing of ___, the sinus rate is slower.
Intraventricular conduction abnormality more pronounced in lead
V2. No evidence of pacing is seen.
Rate PR QRS QT QTc (___) P QRS T
96 162 94 ___
___ ___ W/O CONTRAST:
1. No acute intracranial process.
___ ABD PARACENTESIS: IMPRESSION:
1. Technically successful ultrasound guided diagnostic and
therapeutic
paracentesis.
2. 3 L of fluid were removed and no residual ascites is present.
___ RENAL US:
1. Normal renal ultrasound. No hydronephrosis.
2. Ascites, similar to recent CT.
___ MRI/MRA Brain: IMPRESSION:
1. No acute intracranial abnormalities identified. No
concerning enhancing lesions seen. Chronic microangiopathy.
Brain atrophy predominantly in the frontal lobes.
2. Unremarkable MRA of the brain, without evidence of stenosis
or aneurysm.
___ PANOREX: IMPRESSION:
Partially extracted ___ tooth number 30 with remnant tooth in
the mandible. Dental caries of the teeth 29, 22, and 21 and
periapical lucency involving tooth 20.
___ CXR: IMPRESSION:
Comparison to ___. New bilateral basal parenchymal
opacities. With air bronchograms, likely reflecting pneumonia.
In addition, signs of
mild fluid overload have developed. No pleural effusions.
Moderate
cardiomegaly. Mild elongation of the descending aorta.
___ ABD PARACENTESIS: IMPRESSION:
1. Technically successful ultrasound guided diagnostic and
therapeutic
paracentesis.
2. 2 L of fluid were removed.
___: ABD PARACENTESIS
1. Technically successful ultrasound guided diagnostic and
therapeutic
paracentesis.
2. 3.4 L of fluid were removed.
___ SCROTAL US:
1. Large fluid filled hernia in the left groin extending into
the left scrotal sac displacing the testis. The hernia is
filled with ascites fluid.
2. No testicular abnormality identified.
___ CXR:
Small volume free peritoneal air suggested, may be from earlier
today
paracentesis, clinically correlate. Improved cardiopulmonary
findings.
___ ECG:
Normal sinus rhythm. Compared to the previous tracing of ___
premature
atrial depolarizations are no longer present.
Rate PR QRS QT QTc (___) P QRS T
70 136 88 396 413 14 46 66
DISCHARGE LABS:
================================
___ 06:22AM BLOOD WBC-8.1 RBC-2.46* Hgb-7.5* Hct-22.1*
MCV-90 MCH-30.5 MCHC-33.9 RDW-19.8* RDWSD-63.9* Plt ___
___ 06:22AM BLOOD ___ PTT-35.6 ___
___ 06:22AM BLOOD Glucose-183* UreaN-22* Creat-1.0 Na-132*
K-5.0 Cl-96 HCO3-22 AnGap-19
___ 06:22AM BLOOD ALT-11 AST-37 AlkPhos-244* TotBili-1.5
___ 06:22AM BLOOD Albumin-3.8 Calcium-8.4 Phos-3.8 Mg-2.0
Brief Hospital Course:
___ is a ___ y/o M with EtOH cirrhosis (Childs Class C;
decompensations including variceal bleed, hepatic
encephalopathy, and refractory ascites), anxiety, and past
opiate abuse, who was referred in to ___ on ___ for
vomiting x7 days and leakage of ascites from umbilical hernia,
found to have SBO, s/p OR on ___ w/ hernia repair.
Hospital stay was complicated by seizure on ___, hyponatremia,
severe malnutrition, HRS, and SBP.
# Alcoholic cirrhosis: complicated by ascites requiring q5d
paracenteses, SBP, HE, HRS and severe malnutrition. MELD on
discharge 17. Each complication is discussed separately:
## ___ use disorder: social work was engaged with the
patient in-house and offered support and counseling around
difficulty coping with loss and substance abuse. Discussion was
had about need for ongoing abstinence in order for transplant to
be an option.
## Decompensated ascites, SBP: large volume ascites requiring
frequent paracenteses (every 5 days). Because of ongoing ___
(see below), no more than 4L were taken out initially. Last
paracentesis was for 4.5L on ___ in the setting of Cr 0.9.
Diagnostic studies were sent on most peritoneal fluid samples;
with one meeting criteria for SBP by white count. Patient was
already on SBP prophylaxis with ciprofloxacin and was thus
broadened to meropenem given PCN allergy, to good effect. Repeat
peritoneal fluid studies were normal.
##HRS: Notable increase from home creatinine of 0.9 to 2.9 over
a short period of time was concerning for HRS. Diuretics were
stopped and patient underwent two albumin challenges with no
improvement. He was recruited to ___ terlipressin trial and
randomized to one arm to it (double-blind study, assignment
unknown). Cr made a remarkable recovery from 2.9 to 1.2, at
which point the drug was stopped. Cr further improved to 0.9 and
remained in 0.9-1.1 range. Cr at discharge 1.0.
##HE: ongoing hepatic encephalopathy in setting of acute
decompensation, which was managed well with lactulose titrated
to ___ BMs/day and rifaximin 550 mg BID. No asterixis at
discharge.
##Severe malnutrition: weight on admission 132.5lb. Wt on
discharge: 147. Mr ___ was initially resistant but ultimately
conceded to having a feeding tube placed under MAC anesthesia on
___. Tube feeds were initiated and brought to goal.
Nutritional supplementation with Ensure was also provided.
Patient was placed on insulin sliding scale given large calorie
boluses.
# Umbilical hernia s/p repair: Mr ___ presented with nausea,
vomiting and inability to take po and was found to have
umbilical hernia that required urgent repair. From a surgical
standpoint, the patient has made good recovery without recurrent
nausea, vomiting or other evidence of obstruction.
# Seizure: patient had a generalized tonic-clonic seizures x2 in
the immediate post-operative setting. MRI head did not show any
acute abnormalities. Neurology was consulted and thought that
seizures likely multifactorial due to general medical health
with contribution from alcohol withdrawal, benzo withdrawal,
electrolyte abnormalities, fluid shifts, meds. He was started on
Keppra 1000 mg BID, with no further episodes. Ativan 1 mg IV
prn:seizure >5 min or >3/hr was available at all times but not
used. Patient was given thiamine, folate, MVI to replete vitamin
deficiencies. Hyponatremia was treated per below.
# Chronic anemia: required blood transfusions prn for Hgb<7. No
active source of bleeding was identified.
# Leukocytosis: one episode of leukocytosis to 15 on ___,
confirmed on repeat testing, without clear source. Patient
endorsed vague urinary symptoms for which vancomycin was added
with resolution of the discomfort and elevated WBC. Cultures
were negative except for urine which revealed yeast. Vancomycin
was completed for a 7 day course.
# Hyponatremia: intermittently to 125 and 127 in the setting of
hyponatremic hypervolemia. Diuretics were held, to good
response. Patient also received intermittent albumin boluses for
repletion and was placed on fluid restriction (1.5L at
discharge), to good effect.
# Hematuria: one episode reported ___. UA obtained 2 hr later
w/ 3 RBC in it, suggesting it was unlikely to be blood or
self-limited. Not witnessed by team. No recurrence.
# Dental: retained tooth fragments reported by patient and noted
on Panorex. Given no evidence of infection or pain, OMFS was not
called in-house.
TRANSITIONAL ISSUES:
====================
[ ] Medication changes:
- Continue lactulose at ___ ml TID and titrate up and down
for ___ BM
- Continue rifaximin 550 mg BID
- Continue ISS
- Furosemide and spironolactone were discontinued; clonazepam
was replaced with trazodone for sleep
- multivitamin was discontinued, as vitamins available through
tube feeds
[ ] Follow up appointments:
- With surgery on ___
- with transplant Hepatology (Dr. ___ ___
- with Neurology re:seizures
- with Palliative care
[ ] will need therapeutic paracenteses every 5 days
[ ] outpatient oral surgery appointment info: ___ floor, (___), ___. Call around 7 am for same day
appointment
[ ] will need repeat EGD ___
#Code status: FULL
#HCP: #CONTACT: ___
Relationship: Wife Phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 15 mL PO BID
2. Gabapentin 300 mg PO TID
3. Mirtazapine 30 mg PO QHS
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. ClonazePAM 2 mg PO QHS:PRN anxiety
6. Furosemide 40 mg PO BID
7. Spironolactone 100 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
10. Sucralfate 1 gm PO QID
11. Pantoprazole 40 mg PO Q24H
12. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral DAILY
13. Escitalopram Oxalate 10 mg PO DAILY
14. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
2. FoLIC Acid 1 mg PO DAILY
3. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
4. LevETIRAcetam 1000 mg PO BID
5. LORazepam 2 mg PO ONCE seizure >5 min, >3 seizures/hr
Duration: 1 Dose
6. Rifaximin 550 mg PO BID
7. Simethicone 80 mg PO QID
8. Sodium Chloride Nasal ___ SPRY NU QID:PRN dry nose
9. Sulfameth/Trimethoprim DS 1 TAB PO/NG DAILY
10. TraZODone 50 mg PO QHS:PRN sleep
11. Lactulose 15 mL PO TID
12. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral DAILY
13. Escitalopram Oxalate 10 mg PO DAILY
14. Fish Oil (Omega 3) 1000 mg PO DAILY
15. Gabapentin 300 mg PO TID
16. Mirtazapine 30 mg PO QHS
17. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
18. Pantoprazole 40 mg PO Q24H
19. Sucralfate 1 gm PO QID
20. Thiamine 100 mg PO DAILY
21. HELD- Furosemide 40 mg PO BID This medication was held. Do
not restart Furosemide until your liver doctor tells you to
restart it
22. HELD- Spironolactone 100 mg PO BID This medication was
held. Do not restart Spironolactone until your liver doctor
tells you to restart it
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
========
Incarcerated and leaking umbilical hernia status post
exploratory laparotomy and repair
Decompensated alcohol-induced cirrhosis
Spontaneous bacterial peritonitis
Hepatorenal syndrome
Severe malnutrition
Hematuria
Urinary tract infection
SECONDARY:
==========
Alcohol use disorder
Anxiety
Scrotal hernia
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 being a part of your care during your
hospitalization at ___!
Why were you hospitalized?
-Because you were having nausea, vomiting and abdominal pain and
you had ascites leaking from your belly button.
What was done for you this hospitalization?
-You had surgery to repair an umbilical hernia that was causing
your symptoms.
-In the post-operative setting you had seizures; we started you
on seizure medications and scanned your head (which did not show
anything concerning)
-You developed worsening swelling in your abdomen, requiring
frequent drainage. You also had an infection in your abdomen,
which we treated with antibiotics
-Your kidney function worsened dramatically due to a
complication of liver disease known as 'hepatorenal syndrome.'
You were recruited for a clinical trial with a drug called
'terlipressin.' You were randomized to one arm of the trial, and
you did very well. Your kidney function came back to normal.
-You had worsening confusion called 'hepatic encephalopathy',
for which we gave you medications to help clear it up.
-You had a urinary tract infection, which we treated with
antibiotics
-We placed a feeding tube to help you gain some of the weight
you had lost because of your liver disease.
What should you do when you leave the hospital?
-Get stronger at rehab!
-Continue to abstain from alcohol, attend one-on-one counseling
and AA meetings
-Keep the feeding tube for nutritional supplementation
-Follow up with the Transplant team, Surgery, Neurology,
Palliative Care
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10146735-DS-17 | 10,146,735 | 26,221,231 | DS | 17 | 2136-12-26 00:00:00 | 2136-12-29 18:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Keflex
Attending: ___.
Chief Complaint:
Hematemesis/Nausea/vomiting
Major Surgical or Invasive Procedure:
Endoscopy - ___
TIPS - ___
History of Present Illness:
___ man with ETOH cirrhosis complicated by HE, SBP on
Bactrim ppx, diuretic refractory ascites, and esophageal varices
with hx of variceal bleeding s/p banding, admitted with
hematemesis. His symptoms started early ___ morning with
melena/passage of clots and hematemesis. He states he had too
many episodes to count. This was accompanied by severe fatigue
and weakness, as well as abdominal cramping. No lightheadedness,
no chest pain, no fevers, no chills.
In ED:
- Initial VS: 98.7 87 106/71 18 100% RA
- Exam: large volume ascites, clear mental status, malnourished.
1 episode of hematemesis ~ 50 cc bright red blood
- Labs: lactate 4.1, Na 127, bicarb 18, BUN 69, Albumin 3.2,
Dbili 0.5, WBC 12.1 (Neutrophils 82%), INR 1.6, Hgb 6.1
- Diagnostic paracentesis done
- Patient was given: 1 unit PRBCs, pantoprazole, octreotide,
fentanyl and Zofran
- Consults: hepatology
- VS prior to transfer: 98.4 81 100/59 14 100% RA
On arrival to the MICU, pt reports no further abdominal cramping
or nausea, no further episodes of hematemesis/melena. Does have
significant back pain. Clear mental status, no lightheadedness.
Past Medical History:
Child's C alcoholic cirrhosis
Esophageal varices requiring banding
HRS
Previous bacterial meningitis
Gastroesophageal reflux disease
Hyperlipidemia
Alcohol abuse now in remission
Depression
Remote history of seizure
Large scrotal hernia
Previous hernia complicated by small-bowel obstruction,
requiring emergent surgery
Social History:
___
Family History:
His brother had cardiac valve replacement. No GI cancers in the
family.
Physical Exam:
ADMISSION EXAM
==============
VITALS: 98.8 79 105/75 17 100% on Vent
GENERAL: Alert, oriented, no acute distress
HEENT: temporal wasting, sclera icteric, MMM, oropharynx clear
NECK: supple, JVP not elevated
LUNGS: CTAB
CV: RRR, no murmurs
ABD: distended, soft, mildly tender throughout. + BS. no
rebound, no guarding
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: telangiectasia on face
NEURO: no asterexis, very sharp
DISCHARGE EXAM
==============
VS: T 98.0, BP 90-95/52-57, HR 62-66, RR 18, SpO2 97/RA
General: very thin male, lying in bed, moves around easily for
exam. NAD.
HEENT: MM, no icterus
Lung: CTAB, no W/R/C
Card: RRR, S1+S2, no M/R/G
Abd: soft, mildly distended, no fluid wave. No TTP.
Ext: no edema
Neuro: no asterixis, able to state days of week backwards
Pertinent Results:
ADMISSION LABS
=============
___ 07:03AM BLOOD WBC-12.1*# RBC-2.44* Hgb-6.1* Hct-19.8*
MCV-81* MCH-25.0* MCHC-30.8* RDW-25.5* RDWSD-71.6* Plt ___
___ 07:03AM BLOOD Neuts-81.9* Lymphs-10.0* Monos-6.6
Eos-0.1* Baso-0.2 Im ___ AbsNeut-9.86*# AbsLymp-1.21
AbsMono-0.80 AbsEos-0.01* AbsBaso-0.03
___ 07:03AM BLOOD ___ PTT-30.0 ___
___ 07:03AM BLOOD Plt ___
___ 07:03AM BLOOD Glucose-161* UreaN-69* Creat-1.2 Na-127*
K-6.0* Cl-94* HCO3-18* AnGap-21*
___ 07:03AM BLOOD ALT-21 AST-41* AlkPhos-85 TotBili-1.5
DirBili-0.5* IndBili-1.0
___ 07:03AM BLOOD Albumin-3.2* Calcium-8.3* Phos-3.2 Mg-2.0
___ 07:44AM BLOOD ___ pO2-25* pCO2-26* pH-7.52*
calTCO2-22 Base XS--1
___ 07:10AM BLOOD Lactate-4.1*
___ 07:44AM BLOOD O2 Sat-36
___ 02:39PM BLOOD freeCa-1.09*
DISCHARGE LABS
==============
___ 06:58AM BLOOD WBC-11.9* RBC-2.84* Hgb-8.1* Hct-25.0*
MCV-88 MCH-28.5 MCHC-32.4 RDW-22.9* RDWSD-70.5* Plt ___
___ 06:58AM BLOOD Plt ___
___ 06:58AM BLOOD ___ PTT-33.2 ___
___ 12:55PM BLOOD Glucose-152* UreaN-18 Creat-0.7 Na-131*
K-3.8 Cl-98 HCO3-24 AnGap-13
___ 06:58AM BLOOD ALT-33 AST-54* AlkPhos-167* TotBili-1.2
___ 12:55PM BLOOD Calcium-7.7* Phos-2.2* Mg-1.9
MICRO
=====
___ 08:51AM ASCITES TNC-319* RBC-403* Polys-5* Lymphs-19*
Monos-10* Mesothe-3* Macroph-58* Other-5*
___ 08:51AM ASCITES TotPro-1.3 Glucose-163
__________________________________________________________
___ 10:17 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: ___ 8:51 am
PERITONEAL FLUID
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 7:30 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 7:03 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING/STUDIES
==============
CHEST (PORTABLE AP) Study Date of ___
FINDINGS:
NG tube has been placed the cold in the stomach. An ET tube has
also been placed with its tip just above the carina, 1.5 cm. The
heart is not enlarged. The aorta is tortuous. Patchy opacities
in the left lower lung field noted. No pleural effusion or
pneumothorax
___ 9:00:00 AM - EGD report
A feeding tube was placed under endoscopic visualization and
advanced into the jejunum. The feeding tube was transferred to
nasal route and secured in place using bridal.
Mosaic appearance, erythema, congestion and friability in the
antrum and stomach body compatible with portal gastroapthy
Varices at the lower third of the esophagus
Otherwise normal EGD to third part of the duodenum
___
Successful right internal jugular access with transjugular
intrahepatic
portosystemic shunt placement with decrease in porto-systemic
pressure
gradient from 15 mm per Hg to 5 mm per Hg. 3 liters of large
pleural effusion
were drained.
Brief Hospital Course:
___ yo man with history of alcoholic cirrhosis CP C, MELD-Na c/b
diuretic refractory ascites, varices, and HRS today of 22 who
presented with variceal bleeding, now s/p TIPS on ___.
#UPPER GIB (variceal):
#s/p TIPS: Presented with hematemesis, started on octreotide
drip, IV pantoprazole, and meropenem (perferred antibiotic
prophylaxis with penicillin allergy). Endoscopy done on
admission revealed varices with stigmata of recent bleeding.
Given multiple previous variceal bleeds and diuretic-refractory
ascites, patient proceeded to have TIPS procedure. Gradient
improved to 5mmHg after procedure, suggesting successful TIPS
placement. His bilirubin elevated slightly after the procedure,
but now is downtrending, indicating a slight ischemic injury
from the procedure; improved by discharge. No evidence of HE
since TIPS. After four days of meropenem in house, he was
transitioned back to his Bactrim prophylaxis on discharge. Will
need ultrasound to follow-up TIPS patency in one week (___).
#ETOH CIRRHOSIS: Childs C, not transplant candidate at the
moment because of malnutrtion. Complicated by
diuretic-refractory ascites, HE, malnutrition (receiving tube
feeds), and bleeding esophageal varices s/p banding. Now s/p
TIPS on ___. Continued home lactulose and rifaximin.
#HISTORY OF HRS: creatinine at baseline throughout admission
(0.7 - 0.9). Midodrine discontinued this admission, given stable
BP off midodrine following TIPS.
#HYPONATREMIA: Na 126 on ___, patient given albumin improved to
130s.
#SEVERE MALNUTRITION: S/p tube feed placement last admission.
Continued on tube feeds. Tolerating regular diet by the time of
discharge. Will continue tube feeds as outpatient to optimize
patient's transplant candidacy.
#SEIZURE DISORDER: last seizure ___ in the setting of
electrolyte abnormalities/ abdominal surgery/ ETOH withdrawal.
Normal head MR at that time. Started on Keppra at that time, no
seizures since. Continued home Keppra.
#DEPRESSION: continued home mirtazapine.
#CHRONIC BACK PAIN: on oxycodone PRN at home. Pt was given a
prescription for oxycodone ___ q4hrs:PRN (this is his home
dose) for 7 days at the time of discharge. He was instructed to
follow-up with the palliative care team within 7 days for
further prescriptions.
#BPH: held tamsulosin in the setting of bleed, restarted prior
to discharge.
TRANSITIONAL ISSUES
===================
[ ] needs ultrasound to assess for TIPS patency in one week
(___)
[ ] discontinued nadolol (as he is now s/p TIPS)
[ ] discontinued midodrine given stable blood pressures, if
persistent hyponatremia, consider restarting. Will recheck
chemistry one week after discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Magnesium Oxide 400 mg PO BID
2. Calcium Carbonate 500 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Escitalopram Oxalate 20 mg PO DAILY
5. Fish Oil (Omega 3) 1000 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Gabapentin 300 mg PO TID
8. Lactulose 30 mL PO TID
9. LevETIRAcetam 1000 mg PO BID
10. LORazepam 1 mg PO Q4H:PRN anxiety
11. Midodrine 10 mg PO BID
12. Mirtazapine 30 mg PO QHS
13. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
14. Pantoprazole 40 mg PO Q24H
15. Rifaximin 550 mg PO BID
16. Simethicone 80 mg PO QID:PRN gas
17. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
18. Tamsulosin 0.4 mg PO QHS
19. Thiamine 100 mg PO DAILY
20. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Medications:
1. Calcium Carbonate 500 mg PO DAILY
2. Escitalopram Oxalate 20 mg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Gabapentin 300 mg PO TID
6. Lactulose 30 mL PO TID
7. LevETIRAcetam 1000 mg PO BID
8. LORazepam 1 mg PO Q4H:PRN anxiety
9. Magnesium Oxide 400 mg PO BID
10. Mirtazapine 30 mg PO QHS
11. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
12. Pantoprazole 40 mg PO Q24H
13. Rifaximin 550 mg PO BID
14. Simethicone 80 mg PO QID:PRN gas
15. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
16. Tamsulosin 0.4 mg PO QHS
17. Thiamine 100 mg PO DAILY
18. TraZODone 50 mg PO QHS:PRN insomnia
19. Vitamin D 1000 UNIT PO DAILY
20.Outpatient Lab Work
ICD-10: 571
Lab: chemistry 10
Please fax results to: ___ ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Esophageal varices, bleeding
Alcoholic cirrhosis
Chronic pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
WHY WERE YOU ADMITTED TO THE HOSPITAL?
You were vomiting blood
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You had an endoscopy (camera passed down your throat into your
stomach), which showed enlarged blood vessels, caused by your
liver disease, in your esophagus (food pipe), which were likely
where the blood was coming from.
- You were treated with several medications to stop the
bleeding.
- You had a TIPS - a procedure to fix the enlarged blood vessels
in your esophagus.
- We watched you for several days after your procedure - you did
well.
WHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL?
- You will see the radiologists (doctors who did the TIPS
procedure) in a week to have an ultrasound of your liver.
- You will get blood tests in 1 week.
- You will continue to take an antibiotic to prevent infection
in your belly.
- You will see your liver doctor in the office.
Followup Instructions:
___
|
10146735-DS-18 | 10,146,735 | 21,502,169 | DS | 18 | 2137-05-05 00:00:00 | 2137-05-05 12:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / Keflex
Attending: ___.
Chief Complaint:
recurrent umbilical hernia
Major Surgical or Invasive Procedure:
Umbilical hernia repair with mesh on ___
History of Present Illness:
___ is a ___ male with alcoholic cirrhosis,
Child's class C, decompensated with variceal bleeding, hepatic
encephalopathy, persistent ascites, and malnutrition. The
patient underwent TIPS procedure ___ and subsequently revised
___ (with good gradients). In addition, patient initially
underwent umbilical hernia repair in ___ with subsequent
re-herniation thought to be in the setting of
medication non compliance and recurrent ascites. Patient
presented ___ for evaluation of incarcerated hernia which was
reducible at that time; however in light of recurrent herniation
requiring reduction and risk of incarceration and strangulation
patient presented to the hospital for definitive repair.
Past Medical History:
Child's C alcoholic cirrhosis
Esophageal varices requiring banding
HRS
Previous bacterial meningitis
Gastroesophageal reflux disease
Hyperlipidemia
Alcohol abuse now in remission
Depression
Remote history of seizure
Large scrotal hernia
Previous hernia complicated by small-bowel obstruction,
requiring emergent surgery
Social History:
___
Family History:
His brother had cardiac valve replacement. No GI cancers in the
family.
Physical Exam:
Gen: Alert, oriented, in NAD.
Abd: Mild pain on palpation at repair site, markedly improved
CV: RRR
Resp: Normal respiratory effort
Neuro: grossly intact
Pertinent Results:
___ 05:27PM GLUCOSE-117* UREA N-16 CREAT-1.1 SODIUM-136
POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-26 ANION GAP-12
Brief Hospital Course:
___ presented to the hospital for his recurrent
umbilical hernia. He underwent an umbilical hernia repair with
mesh placement on ___ ___. Of note, ___
___ the patient received 500 cc of crystalloid, had a blood loss
of 50 cc, and a urine output of 150 cc. Sodium noted to be 132
at time of operation, decreased to 127. Hepatology was consulted
and recommended stopping diuretics and placed him on a 1.5 L
fluid restriction. His sodium levels then normalized. On ___,
the patient was tolerating a regular diet, his foley was
removed. He was monitored closely over the following day for
development of ascites. Mr. ___ was discharged home on ___
in stable condition, off diuretics. He will follow up with Dr.
___ on ___.
Medications on Admission:
clindamycin prior to any dental procedure
Lexapro
folic acid
Lasix
gabapentin
lactulose (hardly ever)
keppra
mirtazapine
Zofran
oxycodone
protonix
rifaximin
spironolactone
Bactrim
Flomax
trazodone
calcium+D
mag ox
fish oil
simethicone
thiamine
Discharge Medications:
1. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Moderate
Reason for PRN duplicate override: d/c oxy
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 4
hours Disp #*20 Tablet Refills:*0
2. Acetaminophen 650 mg PO Q8H
3. Escitalopram Oxalate 20 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Gabapentin 300 mg PO TID
6. LevETIRAcetam 1000 mg PO Q12H
7. Midodrine 10 mg PO BID
8. Mirtazapine 30 mg PO QHS
9. Pantoprazole 40 mg PO Q24H
10. Rifaximin 550 mg PO BID
11. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
12. Tamsulosin 0.4 mg PO QHS
13. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
recurrent umbilical hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___:
You were hospitalized following the repair of your umbilical
hernia. You tolerated this without issue and did well
postoperatively. You experienced some issues with elevation in
your sodium levels and as a result of this your home diuretic
medications were stopped (Lasix and spironolactone).
Instructions:
Weight
It is very important that you monitor your weight very closely,
every morning. Weigh yourself daily, at the same time. If your
weight increases 5 pounds from the time of your discharge, or 2
pounds in one day, you should immediately contact our office or
come to the ED as you may need further evaluation in person.
Diet
You should continue on a fluid restricted diet of 1700 mL (1.7L)
of fluid or less per day. You should make sure not to eat more
than 2g of sodium in one day. You should use common sense: do
not eat foods that make you feel unwell. You should eat small
meals and snacks frequently as this may be easier for you in the
period immediately following surgery.
Wound
Wear your abdominal binder as often as possible. Your wound may
be covered with gauze for comfort or left open to the air. Your
staples/sutures will be removed at your follow up visit in
clinic.
To clean the wound allow warm soapy water to flow over it. Pat
dry. Do not apply creams or ointments, or scrub the area.
Activity
Do not lift anything over 20 lbs for 1 month. Do not strain or
do any exercise which causes you to strain your abdomen. You may
otherwise resume normal activities.
Please do not hesitate to contact our office if you have any
concerns that arise or develop symptoms which concern you.
___
Followup Instructions:
___
|
10146782-DS-28 | 10,146,782 | 22,283,133 | DS | 28 | 2163-11-23 00:00:00 | 2163-11-26 16:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Fish Product Derivatives / Shellfish Derived / Peanut / Grass
___, Standard / Mold Extracts / Cat Hair Std Extract
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with severe asthma, with more than 100 prior
admissions and 17 prior intubations, who presents with SOB. He
was last admitted for an asthma exacerbation last month in the
setting of pneumonia and completed a course of antibiotics. For
the past several days he has had worsening SOB which is
triggered by the changing weather and pollen. He usually takes
prednisone 30mg daily but increased to 60mg daily a few days ago
because of the weather. However, he missed the prednisone dose
today. He does have a cough which is non-productive and denies
fevers or chills. Although his chest feels "tight" he denies any
chest pain or palpitations.
In the ED initial VS were 98.2, 105, 147/98, 16, 98%RA. Labs
notable for normal CBC, chem panel, and lactate. VBG: 7.41, 41,
61, 27. CXR showed central bronchial wall thickening but no
focal consolidations or effusions. Patient was given duonebs and
80mg methylprednisolone. Peak flows were 200, then 270, then 320
following ___ neb. VS prior to transfer were 97.5, 98, 156/96,
95% on 6L.
Currently, the patient states that his breathing is slightly
improved since arriving to the floor.
REVIEW OF SYSTEMS: As noted in HPI. In addition, denies fever,
chills, night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
- Severe asthma with greater than 100 hospitalizations, multiple
intubations, followed by Dr. ___ in ___, plan to refer to
Dr. ___ at ___
- OSA on CPAP at night
- Avascular necrosis of the hip and shoulder from prolonged
steroid use, status post hip replacement (___)
- GERD
- H/o L Achilles tendon rupture s/p repair
Social History:
___
Family History:
Two children with asthma.
Physical Exam:
ADMISSION EXAM:
VS - 98.1, 144/92, 88, 20, 98% on 3L
GENERAL - Very tired-appearing man who repeatedly falls asleep
during the interview and examination
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
HEART - RRR, nl S1-S2, no MRG
LUNGS - Good air movement with use of accessory muscles, diffuse
inspiratory and expiratory wheezes and coarse breath sounds, no
rales
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical lymphadenopathy
NEURO - Oriented x3 but patient very sleepy and did not
participate in neuro exam
DISCHARGE EXAM:
AF, VSS, 95-97%RA at rest, 94% after going up and down 2 flights
of stairs
GENERAL - Alert and awake, interactive, appropriate
LUNGS - Good air movement, diffuse expiratory wheezes, no use of
accessory muscles, respirations unlabored, no crackles
Neuro - AAOx3, strength ___ throughout, gait normal
Exam otherwise unchanged since admission
Pertinent Results:
RELEVANT LABS:
___ 08:45PM BLOOD WBC-8.9 RBC-5.22 Hgb-16.0 Hct-47.6 MCV-91
MCH-30.5 MCHC-33.5 RDW-12.8 Plt ___
___ 08:45PM BLOOD Neuts-58.3 ___ Monos-6.2 Eos-6.7*
Baso-1.8
___ 06:00AM BLOOD ___ PTT-32.2 ___
___ 08:45PM BLOOD Glucose-102* UreaN-14 Creat-0.8 Na-145
K-4.1 Cl-107 HCO3-27 AnGap-15
___ 06:00AM BLOOD Calcium-9.4 Phos-2.4* Mg-2.2
___ 08:55PM BLOOD ___ O2 Flow-5 pO2-61* pCO2-41
pH-7.41 calTCO2-27 Base XS-0 Intubat-NOT INTUBA
___ 08:58PM BLOOD Lactate-1.3
IMAGING:
___ CXR:
Frontal and lateral views of the chest were compared to previous
exam from ___. The lungs are clear of confluent
consolidation. There is, however, evidence of bronchial wall
thickening centrally. There is no effusion. The
cardiomediastinal silhouette is normal. Osseous and soft tissue
structures are unremarkable.
IMPRESSION: No focal consolidation. Suggestion of bronchial wall
thickening which can be seen in the setting of bronchitis.
Clinical correlation recommended.
Brief Hospital Course:
___ y/o M with severe refractory asthma, with numerous prior
admission and intubations, who presents with SOB and cough,
symptoms c/w asthma exacerbation.
# Asthma exacerbation: SOB most likely due to repeat asthma
exacerbation given similar symptoms to prior asthma
exacerbations and diffuse wheezing on exam. Patient with severe
refractory asthma with last admission ~1 month ago and inability
to taper down steroids (chronically on prednisone 30mg daily).
Despite increasing prednisone to 60mg daily a few days ago and
taking nebs every ___ hours, patient was getting worse at home.
Likely triggers this time due to change in weather and missed
dose of prednisone. CXR showed bronchial wall thickening which
can be seen in bronchitis, but no evidence of pneumonia.
Leukocytosis developed only after steroids were given. No fever
to suggest infection. EKG w/o ischemic changes. Low suspicion
for PE. Symptoms improved after receiving 80mg IV and albuterol
nebs q3-4 hours, along with ipratropium nebs q6 hours and home
dose ___ home dose, Symbicort equivalent of home dose
Advair, and fexofenadine equivlanet of home dose loratidine.
Patient started on prednisone 60mg daily. Patient also
continued on home dose PPI and Bactrim ppx for chronic steroid
use. Peak flow on presentation was 200 in the ED, at the time
of discharge, improved to 350 (patient baseline 450-550). At
the time of discharge, patient able to ambulate up and down 2
flights of stairs with mild SOB but O2 sat 94% on RA. Plan to
continue home inhalers, nebs, magnesium, Singular, and start
prednisone 60mg daily until patient follows up with Dr. ___ on
___. Also set up appointments for patient to see Dr.
___, Dr. ___ at ___, and
___ (Allergy). Should also address with PCP or Dr.
___ repeat BMD (normal in ___ and potentially
restarting VitD/Ca, or starting bisphosphonates.
# OSA: Continued nightly CPAP.
# H/o avascular necrosis: Patient with AVN of left hip s/p THR
in ___. Denies any further hip or shoulder pain. Patient was
to follow up with Dr. ___ on ___. Appointment
rescheduled for ___.
# GERD: Continued pantoprazole.
# Transitional issues:
- code status: full
- follow up:
- Dr. ___ ___
- Dr. ___
- Dr. ___ ___
- ___ (Allergy) ___
- Dr. ___ ___
- Dr. ___ to address prednisone taper on follow up on ___
- Dr. ___ Dr. ___ to address repeat BMD and starting
VitD/Ca, and/or bisphosphonates
Medications on Admission:
- Prednisone 30mg daily (though increased to 60mg daily past
several days since the weather has changed)
- Bactrim 400-80mg daily
- Albuterol 90mcg; 2 puffs Q4h prn
- Fluticasone 50mcg; 1 nasal spray BID
- Montelukast 10mg daily
- Symbicort 160-4.5 mcg; 2 inh BID
- DuoNeb 0.5 mg-3 mg; QID prn
- Claritin 10mg daily
- Nicotine lozenge q2-4hrs
- Pantoprazole 40mg Q12h
- Magnesium 500mg
Discharge Medications:
1. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*21 Tablet(s)* Refills:*0*
2. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Inhalation every four (4) hours as needed for shortness
of breath or wheezing.
4. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal BID (2 times a day).
5. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Symbicort 160-4.5 mcg/actuation HFA Aerosol Inhaler Sig: Two
(2) Inhalation twice a day.
7. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
8. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
10. Commit 4 mg Lozenge Sig: One (1) Buccal q2-4h as needed for
craving: do not exceed 20 pieces in 24 hours.
Disp:*200 pieces* Refills:*0*
11. magnesium oxide 500 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Asthma exacerbation
Allergic rhinitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent (able to walk up and
down two flights of stairs)
Discharge Instructions:
Mr. ___,
It was a pleasure participating in your care at ___. You were
admitted because you had an asthma exacerbation likely triggered
by pollens. We treated you with IV steroids and an increased
prednisone dose (see below), as well as nebulizers.
Please attend (or reschedule) your follow up appointments listed
below.
We made the following changes to your medication:
INCREASED prednisone from 30mg to 60mg daily (please continue
this dose until you follow up with Dr. ___
Please discuss with Dr. ___ Dr. ___ starting
calcium and Vitamin D supplements
Followup Instructions:
___
|
10146782-DS-30 | 10,146,782 | 27,318,446 | DS | 30 | 2164-03-05 00:00:00 | 2164-03-06 05:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Fish Product Derivatives / Shellfish Derived / Peanut / Grass
___, Standard / Mold Extracts / Cat Hair Std Extract
Attending: ___
___ Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M with PMHx of refractory asthma with > 100 hospitalization
and 17 past intubations now presenting with wheezing, SOB,
worsening over the past 2 days.
Patient developed cough and shortness of breath for the past
week that he attributes to the hot weather. Over the past 2
days, patient has had worsening SOB and wheezing, not managed
with home nebulizers. Prior to presentation in the ED, the
patient used his nebulizers 6 times on the AM of presentation
with no changes in symptoms. He reports that he increased his
prednisone dose from 30mg daily to 80mg daily 3 days ago. His
cough is productive of sputum, described as clear, thick and
yellow. He reports that he had fever of 99.2 1 week ago. He has
also noticed DOE, which the patient does not experience at
baseline.
Of note, he reports that his wife has been ill with coughing and
runny nose.
Initial vitals upon arrival to the ED: 98.0 103 153/98 22 97%
RA. In the ED, per verbal report, the patient is speaking in
full sentences though having difficulty completing full
sentences, but with no accessory muscle use and no tachypnea.
The patient had a CXR which showed no effusions or
consolidations concerning for PNA. The patient was given 2
Duo-Neb treatments, IV magnesium, and IV solumedrol 125mg ONCE.
On arrival to the MICU, the patient is feeling tired, but denies
chest pain, chest tightness, shortness of breath, abdominal
pain, nausea, or vomiting.
Past Medical History:
- Severe asthma with greater than 100 hospitalizations, multiple
intubations (17), followed by Dr. ___ in ___, plan to refer
to Dr. ___ at ___
- ___ on CPAP at night
- Avascular necrosis of the hip and shoulder from prolonged
steroid use, status post hip replacement (___)
- GERD
- H/o L Achilles tendon rupture s/p repair
Social History:
___
Family History:
Two children with asthma as well as mother with asthma.
Physical Exam:
Admission:
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: bilateral wheezes, no 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: same as above except:
VS: 97% RA with ambulation
Lungs: CTAB
Pertinent Results:
___ 12:00PM BLOOD WBC-12.9*# RBC-5.20 Hgb-15.6 Hct-47.5
MCV-91 MCH-30.1 MCHC-32.9 RDW-13.5 Plt ___
___ 12:00PM BLOOD Neuts-66.4 ___ Monos-7.9 Eos-1.4
Baso-0.6
___ 12:00PM BLOOD Glucose-91 UreaN-15 Creat-1.0 Na-140
K-5.1 Cl-109* HCO3-21* AnGap-15
___ 01:40PM URINE Color-Yellow Appear-Clear Sp ___
___ 01:40PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 01:40PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
TransE-<1
___ 01:40PM URINE CastHy-5*
___ 01:40PM URINE ___ 1:40 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
CXR: FINDINGS: Frontal and lateral views of the chest were
obtained. The heart is of normal size with normal
cardiomediastinal contours. Bilateral streaky linear perihilar
opacities are compatible with reactive airway disease,
progressed since ___ and similar to ___. The lungs
are otherwise clear. No lobar consolidation, pleural effusion,
or pneumothorax. The osseous structures are unremarkable. No
radiopaque foreign bodies.
IMPRESSION: Bilateral streaky perihilar opacities, compatible
with reactive airway disease, similar to ___ though
progressed since ___.
Brief Hospital Course:
Mr. ___ was admitted to ___ with an exacerbation of his
reactive airway disease, asthma vs COPD vs bronchiectasis. He
was started on standing bronchodilator nebs and prednisone 60mg
daily and admitted to the ICU. His CXR showed no PNA. His
respiratory status improved dramatically in the next ___ and his
oxygen sat was 97% RA with ambulation. He was encouraged to quit
smoking again and provided script for nicotine lozenges. He was
discharged with a plan to taper prednisone in the following
manner: take 60mg x 4 days, 50mg x 4 days, 40mg x 4 days, then
return to usual dose of 30mg daily. He should likely have a high
res CT chest as an outpatient to eval for bronchiectasis. He may
also have an element of COPD contributing to this picture. He
will follow up with PCP in next few days, pulmonary next month.
Medications on Admission:
1. DuoNeb (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL
Inhalation Q4H:PRN shortness of breath or wheezing
2. fluticasone 220 mcg/actuation Inhalation BID 6 puffs twice a
day
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. Montelukast Sodium 10 mg PO DAILY
5. Loratadine 10 mg Oral Daily
6. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
7. Omeprazole 20 mg PO BID
8. Tiotropium Bromide 1 CAP IH DAILY RX *Spiriva with HandiHaler
18 mcg 1 cap IH daily
9. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation Q4H:PRN shortness of breath or wheezing
10. Nicotine Lozenge 4 mg PO Q1H:PRN craving
11. PredniSONE 30mg PO daily
Discharge Medications:
1. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation Q4H:PRN shortness of breath or wheezing
RX *DuoNeb 0.5 mg-3 mg (2.5 mg base)/3 mL 1 nebulizer IH every
four (4) hours Disp #*60 Vial Refills:*0
2. fluticasone *NF* 220 mcg/actuation Inhalation BID
6 puffs twice a day
RX *Flovent HFA 220 mcg 6 puffs IH twice a day Disp #*1 Inhaler
Refills:*0
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. Montelukast Sodium 10 mg PO DAILY
RX *Singulair 10 mg 1 Tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Loratadine *NF* 10 mg Oral Daily Reason for Ordering: Wish to
maintain preadmission medication while hospitalized, as there is
no acceptable substitute drug product available on formulary.
6. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
RX *Serevent Diskus 50 mcg 1 discus IH every twelve (12) hours
Disp #*1 Inhaler Refills:*0
7. Omeprazole 20 mg PO BID
8. Tiotropium Bromide 1 CAP IH DAILY
RX *Spiriva with HandiHaler 18 mcg 1 cap IH daily Disp #*1
Inhaler Refills:*0
9. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation Q4H:PRN shortness of breath or wheezing
RX *albuterol sulfate 90 mcg 2 puffs IH every four (4) hours
Disp #*1 Inhaler Refills:*0
10. Nicotine Lozenge 4 mg PO Q1H:PRN craving
RX *nicotine (polacrilex) 4 mg 1 lozenge by mouth every hour
Disp #*120 Lozenge Refills:*0
11. PredniSONE 60 mg PO DAILY
RX *prednisone 10 mg 1 Tablet(s) by mouth as directed Disp #*91
Tablet Refills:*0
RX *prednisone 10 mg 1 Tablet(s) by mouth as directed Disp #*100
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Asthma/COPD exacerbation
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 difficulty breathing.
This was likely due to an exacerbation of your asthma. You may
also have COPD, another chronic lung disease. It is important
you take all of your breathing medications every day. You should
stop smoking to avoid having more of these episodes.
.
Some of your medications were changed during this admission:
START prednisone taper, take 60mg daily for one week, then 40mg
daily for one week, then 20mg daily for one week, then 10mg
daily for one week.
.
You should continue to take all of your other medications as
prescribed.
Followup Instructions:
___
|
10146782-DS-33 | 10,146,782 | 25,573,030 | DS | 33 | 2164-05-14 00:00:00 | 2164-05-15 20:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Fish Product Derivatives / Shellfish Derived / Peanut / Grass
___, Standard / Mold Extracts / Cat Hair Std Extract
Attending: ___
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male with history of severe asthma requiring
numerous hospitalizations and intubations in the past, now
re-presenting with recurrent dyspnea and cough for 2 days. His
productive cough started about 2 days ago, in the absence of any
other URI symptoms. His shortness of breath began yesterday,
for which he usually tries his nebulizer and a Z-pack. His
nebulizer machine was not working overnight, he actually went to
work the next day and he called ___ in the morning to try to get
another script to replace it. When this did not work, he drove
himself from work to the pharmacy to pick one up and then gave
himself a treatment on the way home. Before he got a chance to
take his high-dose prednisone, he decided to come to the ED. He
has been taking 50mg prednisone in a slow taper, but the goal
dose was 30mg every other day until he was able to get off
steroids entirely.
.
He was previously discharged from ___ after a similar
presentation and ICU admission, felt to be consistent with a
combination of asthma and COPD exacerbations. He received
albuterol/ipratropium nebs q6h with clinical improvement in
wheezing, azithromycin for antibiotic coverage, and was
discharged on a prednisone taper to be determined by his
outpatient pulmonologist, Dr. ___. Prior peak flows
were 350 on ___ and 300 on ___. Prior admissions this year
have followed a similar pattern, none of which have required
intubations and have lasted ___ days.
.
In the ED, initial vitals were: 101.4, ___, 92% on 4L
O2. He received solumedrol 125mg IV, Magnesium 2g IV, Cefepime
1g IV, Levofloxacin 750mg IV, Combivent + albuterol nebs, and 1g
tylenol for fever. Given his continued tachypnea and
tachycardia as well as his prior history of severe asthma, the
decision was made to admit him to the ICU for further
monitoring. On transfer to the MICU, vitals were: Sats 91% RA,
RR 28, HR 120, BP 121/102 (151/96 prior).
.
On arrival to the MICU, he is still very wheezy, but comfortable
on RA.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
- Severe asthma
--- ___: 6 hospitalizations since beginning of the year, all
lasting ___ days
--- More than 100 lifetime hospitalizations with multiple
intubations (17)
--- Most recent prolonged admission was in ___, which was
complicated by MRSA and xanthomonas bronchitis
- OSA on CPAP at night
- GERD
- Avascular necrosis of the hip s/p left TKR ___ and shoulder
repair from prolonged steroid use
- L Achilles tendon rupture s/p repair
Social History:
___
Family History:
Maternal history of cancer and asthma.
Physical Exam:
Admission Physical Exam:
Vitals: T: BP: 138/77 P: 93 R: 24 O2: 95% on RA
General: Alert, oriented, mild respiratory distress
HEENT: Sclera anicteric, MMM, oropharynx clear but mildly
difficult to visualize, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: diffuse inspiratory and expiratory wheezing with
prolonged expiratory phase. No crackles or rhonchi
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: nonfocal exam with CNII-XII grossly intact and full
strength and sensation bilaterally
Discharge Physical Exam:
VS - 97, 131/88 (to to 160s systolic), 87 (up to 130s), 22, 96RA
GENERAL - sleeping with CPAP
HEENT - EOMI, sclerae anicteric, MMM, OP clear
HEART - RR, nl S1-S2, no MRG
LUNGS - Diffuse inspiratory and expiratory wheezes with
prolonged I/E ratio, improved from yesterday. no rales. Speaking
in full sentences. No accessory muscle use.
ABDOMEN - NABS, soft and adipose/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
MSK - Full ROM throughout.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle and
sensation grossly intact throughout
Pertinent Results:
ADMISSION LABS:
___ 11:20PM GLUCOSE-185* UREA N-11 CREAT-0.8 SODIUM-140
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-23 ANION GAP-16
___ 11:20PM CK(CPK)-166
___ 11:20PM CK-MB-4 cTropnT-<0.01
___ 11:20PM CALCIUM-8.5 PHOSPHATE-2.5* MAGNESIUM-2.4
___ 11:20PM WBC-15.5* RBC-5.09 HGB-15.3 HCT-46.1 MCV-91
MCH-30.1 MCHC-33.2 RDW-13.1
___ 11:20PM NEUTS-94.0* LYMPHS-3.9* MONOS-1.2* EOS-0.8
BASOS-0.2
___ 11:20PM PLT COUNT-282
___ 11:20PM ___ PTT-32.4 ___
___ 06:54PM LACTATE-1.4
___ 06:40PM GLUCOSE-102* UREA N-12 CREAT-0.9 SODIUM-141
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-27 ANION GAP-13
___ 06:40PM estGFR-Using this
___ 06:40PM WBC-13.2* RBC-5.43 HGB-16.5 HCT-48.9 MCV-90
MCH-30.5 MCHC-33.8 RDW-13.0
___ 06:40PM NEUTS-73.3* LYMPHS-11.8* MONOS-10.0 EOS-4.4*
BASOS-0.5
___ 06:40PM PLT COUNT-329
CBC
___ 11:20PM BLOOD WBC-15.5* RBC-5.09 Hgb-15.3 Hct-46.1
MCV-91 MCH-30.1 MCHC-33.2 RDW-13.1 Plt ___
___ 06:40AM BLOOD WBC-21.6* RBC-4.51* Hgb-13.5* Hct-41.4
MCV-92 MCH-30.1 MCHC-32.7 RDW-13.2 Plt ___
___ 07:50AM BLOOD WBC-13.6* RBC-4.44* Hgb-13.5* Hct-41.0
MCV-92 MCH-30.5 MCHC-33.0 RDW-13.3 Plt ___
___ 08:21AM BLOOD WBC-17.4* RBC-4.68 Hgb-14.6 Hct-42.4
MCV-91 MCH-31.2 MCHC-34.4 RDW-13.4 Plt ___
___ 07:05AM BLOOD WBC-16.9* RBC-4.45* Hgb-13.7* Hct-40.1
MCV-90 MCH-30.8 MCHC-34.2 RDW-13.4 Plt ___
___ 11:20PM BLOOD Neuts-94.0* Lymphs-3.9* Monos-1.2*
Eos-0.8 Baso-0.2
CHEMISTRY:
___ 11:20PM BLOOD Glucose-185* UreaN-11 Creat-0.8 Na-140
K-4.3 Cl-105 HCO3-23 AnGap-16
___ 06:40AM BLOOD Glucose-102* UreaN-18 Creat-0.8 Na-142
K-3.9 Cl-110* HCO3-26 AnGap-10
___ 07:50AM BLOOD Glucose-131* UreaN-15 Creat-0.8 Na-146*
K-3.4 Cl-112* HCO3-26 AnGap-11
___ 08:21AM BLOOD Glucose-81 UreaN-14 Creat-0.8 Na-145
K-3.5 Cl-108 HCO3-27 AnGap-14
___ 07:05AM BLOOD Glucose-81 UreaN-19 Creat-0.8 Na-146*
K-3.4 Cl-107 HCO3-29 AnGap-13
___ 06:40AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.2
___ 07:50AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.9
___ 08:21AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.9
___ 07:05AM BLOOD Calcium-9.0 Phos-4.9* Mg-2.0
OTHER LABS:
___ 11:20PM BLOOD CK-MB-4 cTropnT-<0.01
___ 11:20PM BLOOD CK(CPK)-166
___ 11:20PM BLOOD ___ PTT-32.4 ___
MICRO:
Blood cultures ___: no growth
IMAGING:
CXR ___: IMPRESSION: No acute cardiopulmonary pathology.
ECHO ___: The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Left ventricular systolic function is
hyperdynamic (EF 75%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
Brief Hospital Course:
CHIEF COMPLAINT: SOB
REASON FOR ADMISSION: ___ year old male with multiple prior
hospitalizations requiring intubation for asthma exacerbation
and ?additional pulmonary disease, re-presenting with acute
onset dyspnea consistent with an asthma exacerbation after a
recent discharge for the same.
# Asthma exacerbation: Exacerbating factors for this
presentation include broken nebulizer machine, life stressors,
smoking, weather, and URI. Outpatient management of this
patient's asthma has been extremely difficult, as he has
required 6 hospitalizations this year despite back-up plans of
high-dose prednisone as needed and very high doses of inhaled
glucocorticoids and controller meds. During his ICU course he
received standing albuterol and ipratropium q2h nebs, prednisone
60mg, azithromycin and continued his home regimen of
flovent,singulair and salmeterol. On the medicine floor, he
completed a 5 day azithromycin course. His PCP prophylaxis with
bactrim was continued, and calcium/vitamin D given chronic
intermittent high dose steroid use. Outpatient consideration for
thermoplasty and consideration of therapy with zolair was
discussed in emails with outpatient providers. After spacing of
his nebulizers, he was discharged on a prednisone taper starting
at 60mg daily x7 days, then to 40mg until followup with his PCP.
He has an appointment with his pulmonologist Dr. ___ in
___, but he was encouraged to make an earlier appointment
if possible.
# Anxiety: Patient cited multiple life stressors, including
marital discord, which are likely contributing to his frequent
asthma exacerbations. Was seen by social work who recommended
outpatient resources. He was given ativan 1mg prn to help with
anxiety, which he will continue on discharge.
# Smoking cessation: Patient reports interest in smoking
cessation. He used nicotine lozenges during admission and also
expressed interest in discussing Chantix with his PCP.
# OSA on CPAP: Patient was on home CPAP at night, with the
exception of the night spent in the ICU for more frequent
nebulizer therapy.
# GERD: Likely secondary to chronic steroid use, continued his
home dose PPI.
TRANSITIONAL ISSUES:
Asthma exacerbation - He is on a steroid taper with close
outpatient followup
Life stressors - He was given a list of outpatient resources by
SW
Smoking cessation - He was given lozenges, and expressed
interest in discussing Chantix with outpatient providers.
MEDICATION CHANGES:
START nicotine lozenges
START calcium and vitamin D
START prednisone taper at 60mg daily x7days, then to 40mg daily
until following up with PCP
START lorazepam for anxiety
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Fluticasone Propionate NASAL 2 SPRY NU DAILY
2. Montelukast Sodium 10 mg PO DAILY
3. Omeprazole 20 mg PO BID
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
6. Loratadine *NF* 10 mg Oral daily allergies
7. Tiotropium Bromide 1 CAP IH DAILY
8. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
9. Fluticasone Propionate 110mcg 12 PUFF IH BID
home dose of 220mcg, 6 puffs BID
10. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation q4h SOB
11. Magnesium Oxide 400 mg PO DAILY
12. Guaifenesin ER 1200 mg PO Q12H
13. PredniSONE 50 mg PO DAILY
for the last 3 days. Goal dose 30mg every other day for now,
until able to taper.
Discharge Medications:
1. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
twice daily Disp #*120 Tablet Refills:*0
2. Nicotine Lozenge 4 mg PO Q2H:PRN desire to smoke
RX *nicotine (polacrilex) 4 mg 1 lozenge every two hours as
needed Disp #*60 Lozenge Refills:*0
3. Calcium Carbonate 500 mg PO BID
RX *calcium carbonate [Calcium 600] 600 mg (1,500 mg) 1
tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*0
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. fluticasone *NF* 220 mcg/actuation INHALATION 12 PUFFS BID
7. Magnesium Oxide 400 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation q4h SOB
10. Guaifenesin ER 1200 mg PO Q12H
11. Loratadine *NF* 10 mg Oral daily allergies
12. Montelukast Sodium 10 mg PO DAILY
13. Omeprazole 20 mg PO BID
14. PredniSONE 60 mg PO DAILY Duration: 7 Days
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*21 Tablet
Refills:*0
15. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
16. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
17. Lorazepam 1 mg PO BID:PRN anxiety
RX *lorazepam 1 mg 1 tablet by mouth twice daily Disp #*14
Tablet Refills:*0
18. PredniSONE 40 mg PO DAILY
Start taking after finishing 7 days of prednisone 60mg.
Continue this dose until otherwise directed by your doctor.
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Asthma exacerbation
Tachycardia
Anxiety
Tobacco use
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 be a part of your care at ___. You were
admitted for increasing shortness of breath. Your symptoms were
consistent with an asthma exacerbation. You were treated with
nebulizers, systemic and inhaled steroids, and your home
medications. You will be on a prednisone taper for several
weeks. Given the side effects of steroids, you were given
calcium and vitamin D in the hospital, which you should continue
at home.
Your heart rate was very fast during hospitalization. Causes of
your elevated heart rate include some of the medications that
you were on, as well as anxiety. You were given low dose
benzodiazepines to help with anxiety and were seen by the
___ social worker to discuss coping mechanisms and
outpatient therapy resources. It is strongly suggested that you
pursue out patient counseling as well as psychiatry to help
address your anxiety which is likely contributing to your asthma
exacerbations. You can continue to take the low dose
anti-anxiolytic as an outpatient, but must not drink or operate
machinery on the medication.
You were counseled on smoking cessation during your stay. You
were given nicotine lozenges to help with cravings during
hospitalization. We strongly encourage continued smoking
cessation in the outpatient setting, as smoking is contributing
to your frequent asthma exacerbations. You are being sent home
with lozenges and should talk to your primary care doctor about
___ prescription medicine called Chantix.
Followup Instructions:
___
|
10146806-DS-17 | 10,146,806 | 27,994,357 | DS | 17 | 2131-12-18 00:00:00 | 2131-12-18 19:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
chest pain, PE
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMH significant for h/o DVT in ___, kidney stones,
and OSA who presented to OSH with chest pain. He woke up one day
prior to admission with left upper quadrant abdominal pain as
well as pleuritic chest pain. He states this pain felt different
from his kidney stone pain. Upon arrival to OSH, his SpO2 was
85%. CTA chest showed bilateral pulmonary emboli as well as
multifocal ground-glass and nodular opacities suspicious for an
atypical infection. Patient denies cough but does not mild SOB.
He was given one dose of lovenox, then transferred to ___ for
further management as his PCP is based at ___.
Of note, the patient states that he recently passed a kidney
stone on the ___ prior to admission. He notes that for the
2 weeks leading up to passing the stone he was very sedentary,
rarely leaving the couch and taking oxycodone. Otherwise no
recent travel. Does not smoke. No recent leg swelling.
The patient was diagnosed with a DVT in ___. This was felt to
be provoked in the setting of left calf injury. The patient
denied any immobility or recent travel at that time.
Hypercoagulable workup was done at ___, though the
results were not obtained. He was treated with coumadin for 6
months.
In the ED, initial vitals were: 98.9 98 160/80 16 99% 2L. Labs
were notable for WBC 11.7 and Cr 0.9. EKG showed normal sins
rhythm.
On the floor, patient stable with vitals notable for 98.2;
156/82, 86; 20 99% 2L.
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:
- Deep venous thrombosis: diagnosed in ___, on coumadin for 6
months
- Sleep apnea, uses CPAP
- Kidney stones
- Allergic rhinitis
- S/p appendectomy
- Recurrant PE ___
Social History:
___
Family History:
Mother had colon cancer, breast cancer, CAD, DM, and pulmonary
fibrosis.
Physical Exam:
ADMISSION PE:
Vitals: 98.2; 156/82, 86; 20 99% 2L.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PER
Neck: Supple, JVP not elevated, no LAD appreciated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, equal expansion, but
decreased breath sounds at the bilateral bases limited to pain
Abdomen: Soft, diffuse tenderness to palpation that patient
associates with pain to the Left rib border, non-distended,
bowel sounds present, no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, cyanosis or edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
DISCHARGE PE:
VS: 97.6; 120/60; 69; 18; 97RA
GENERAL: NAD, alert, interactive
HEENT: NC/AT, sclerae anicteric, MMM
LUNGS: Clear to auscultation except minor crackles at b/l bases,
otherwise no w/r/r
HEART: RRR, no MRG
ABDOMEN: NABS, soft/NT/ND.
EXTREMITIES: WWP
NEURO: awake, A&Ox3
Pertinent Results:
ADMISSION LABS:
___ 05:35AM BLOOD WBC-11.7* RBC-4.80 Hgb-14.3 Hct-41.9
MCV-87 MCH-29.8 MCHC-34.2 RDW-13.1 Plt ___
___ 05:35AM BLOOD Neuts-69.0 ___ Monos-5.9 Eos-1.1
Baso-0.3
___ 05:35AM BLOOD ___ PTT-30.0 ___
___ 05:35AM BLOOD Glucose-106* UreaN-15 Creat-0.9 Na-139
K-4.4 Cl-105 HCO3-21* AnGap-17
___ 04:30AM BLOOD Calcium-9.2 Phos-3.5 Mg-2.1
DISCHARGE LABS:
___ 04:30AM BLOOD WBC-7.8 RBC-4.35* Hgb-13.5* Hct-37.6*
MCV-86 MCH-31.0 MCHC-35.9* RDW-12.8 Plt ___
___ 04:30AM BLOOD Plt ___
___ 04:30AM BLOOD Glucose-79 UreaN-17 Creat-0.9 Na-138
K-3.8 Cl-104 HCO3-26 AnGap-12
MICRO: None obtained
STUDIES/IMAGING:
Bilateral Lower Extremity Dopplers - No evidence of deep venous
thrombosis in the bilateral lower extremity veins.
Brief Hospital Course:
___ with PMH significant for h/o DVT who presented with chest
pain. Found to have bilateral pulmonary embolism.
# Bilateral sub-massive pulmonary embolism: pt with hx of
provoked DVT ___ trauma in past and anticoagulated for 6 months
presented to OSH with a ___ possible provoked PE in setting of
immobility with passing of kidney stones. Transferred to ___
for further managment as patient's PCP ___. EKG showed
NSR and no evidence of right heart strain. Bilateral LENIs
without evidence of DVTs. Patient initially with significant
pain but responded well to tylenol, naproxen and PRN oxycodone
and significantly improved this admission. Initiated patient on
warfarin (5mg qHS) with lovenox bridge. Patient will follow up
with PCP ___ on ___ for INR check and further INR
management. Will also consider outpatient hypercoaguable workup
once out of the acute setting of PE given this is patient's ___
PE.
CHRONIC ISSUES:
# Renal Stones: chronic, follows with Dr. ___ with f/u
scheduled for next week. Continued Flomax qD
# OSA - on home CPAP, continued as inpatient
# Primary Proph: continued ASA
TRANSITIONAL ISSUES:
- INR check ___ and f/u appointment with Dr. ___.
- Consider outpatient hypercoaguable workup and referral to
hematology regarding duration of anticoagulation.
- F/U with Urologist, Dr. ___ for next week to
discuss further w/u for recurrent kidney stones.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Tamsulosin 0.4 mg PO QHS
3. Ascorbic Acid ___ mg PO Frequency is Unknown
4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
3. Tamsulosin 0.4 mg PO QHS
4. Acetaminophen 650 mg PO Q6H:PRN fever, pain
Do not take more than 3 grams per day total dose.
5. Docusate Sodium 100 mg PO BID
6. Enoxaparin Sodium 100 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 100 mg/mL 100 mg twice a day Disp #*30 Syringe
Refills:*0
7. Naproxen 500 mg PO Q12H
RX *naproxen [Naprosyn] 500 mg 1 tablet(s) by mouth BID:PRN Disp
#*30 Tablet Refills:*0
8. Senna 8.6 mg PO BID
9. Warfarin 5 mg PO DAILY16
RX *warfarin 5 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*3
10. Ascorbic Acid ___ mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Pulmonary Embolism
Secondary Diagnosis:
- Obstructive Sleep Apena
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 during your hospitalization.
You were admitted for chest pain and found to have bilateral
pulmonary emboli. These are likely due to you recent immobiltiy
when you were passing your kidney stone. It is also possible
that you have a syndrome that results in the formation of blood
clots more easily. You will need to take blood thinners (lovenox
and coumadin) and monitor your INR with your primary care
doctor. You should also be evaluated for a blood clotting
disorder with you primary care doctor, and potentially a blood
doctor (___).
We will discharge you with a pain medication (naproxen). To
prevent stomach upset, take this with meals. Do not take this
medication for more than one week. Also, should you take
oxycodone, do not drive while taking this medication, as it can
cause sleepiness. We encourage you to drink plenty of fluids. We
are glad you are feeling better and we wish you the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10146806-DS-18 | 10,146,806 | 20,658,951 | DS | 18 | 2134-11-28 00:00:00 | 2134-11-28 19:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cath (___)
History of Present Illness:
Mr. ___ is a ___ with history of hypertension, DVT with PEs
in ___, recent equivocal exercise stress test presenting with
chest pain.
Patient reports that he has had a few months of intermittent
mild, burning, left parasternal chest pain. Patient is not sure
if there is an exertional component to the pain. Not associated
with nausea, vomiting, arm tingling, syncope. He had an exercise
EKG stress test on ___ where he exercised to ___ METS with
good HR and BP response. He developed typical anginal symptoms
with lateral STD and 1mm STE in aVR. He was slated to follow up
with cardiology but since that time he noticed ongoing mild
chest
tightness in the L chest that was about ___. This has been
similar in character to his pain during the stress test but has
been much more mild without exertional component, radiation,
associated diaphoresis, nausea, vomiting, or palpitations. It
has
occasionally been associated with shortness of breath. Since
this
pain was persistent he presented to the ED.
Notably, patient has history of bilateral pulmonary emboli in
___ after being very sedentary at home due to pain related to
kidney stones. He previously developed a distal DVT in the left
leg in ___ after being hit in the knee with a hockey puck. Both
of these episodes were considered provoked, and he was treated
with ___ months of anticoagulation.
In the ED he was reportedly chest pain free, with stable vitals
on presentation. He had a negative troponin x1 and received no
medications. His CXR had no acute cardiopulmonary process. His
EKG was not changed.
On arrival to the floor, patient reported ___ dull L chest pain
without radiation and mild shortness of breath. An EKG revealed
NSR, sub-mm STE in v1 without elevation in contiguous leads, and
no other TWI or STD. Nitroglycerin x1 without improvement in
pain. He received ASA 243 and Atorvastatin 80mg.
Past Medical History:
- Deep venous thrombosis: diagnosed in ___, on coumadin for 6
months
- Sleep apnea, uses CPAP
- Kidney stones
- Allergic rhinitis
- S/p appendectomy
- Recurrant PE ___
Social History:
___
Family History:
Mother had colon cancer, breast cancer, CAD, DM, and pulmonary
fibrosis.
Physical Exam:
ADMISSION EXAM
==============
GENERAL: NAD, WDWN
HEENT: AT/NC, EOMI
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi
ABDOMEN: Nondistended, nontender
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
DISCHARGE EXAM
==============
General: seated comfortably in chair
Heart: rrr, no mrg
Lungs: breathing comfortably, good air movement, ctab
Abdomen: soft, ntnd
Neuro: A&Ox3
Affect: pleasant but anxious
Pertinent Results:
ADMISSION LABS
=============
___ 03:45AM BLOOD cTropnT-<0.01 proBNP-17
___ 09:00AM BLOOD cTropnT-<0.01
___ 03:02PM BLOOD CK-MB-1 cTropnT-<0.01
___ 03:45AM BLOOD WBC-7.8 RBC-4.84 Hgb-14.5 Hct-42.9 MCV-89
MCH-30.0 MCHC-33.8 RDW-12.3 RDWSD-40.0 Plt ___
___ 03:45AM BLOOD Glucose-91 UreaN-24* Creat-0.8 Na-141
K-4.5 Cl-103 HCO3-26 AnGap-12
___ 03:45AM BLOOD ALT-38 AST-27 CK(CPK)-98 AlkPhos-64
STUDIES
======
___ cardiac catheter: left main 30% distal, LAD 30% mid,
60% diag, LCX 40% mid, RCA 50% PDA, 60% PL
___ echocardiogram: Suboptimal image quality. Normal left
ventricular wall thickness, cavity size, and regional/global
systolic function. Mild right ventricular dilatation with
preserved systolic function. No valvular abnormalities or
pathologic flow identified.
DISCHARGE LABS
=============
___ 07:15AM BLOOD WBC-7.9 RBC-4.95 Hgb-14.8 Hct-44.7 MCV-90
MCH-29.9 MCHC-33.1 RDW-12.4 RDWSD-40.9 Plt ___
___ 07:15AM BLOOD Glucose-90 UreaN-21* Creat-1.0 Na-140
K-4.9 Cl-100 HCO3-28 AnGap-12
___ 03:45AM BLOOD ALT-38 AST-27 CK(CPK)-98 AlkPhos-64
___ 03:45AM BLOOD cTropnT-<0.01 proBNP-17
___ 09:00AM BLOOD cTropnT-<0.01
___ 03:02PM BLOOD CK-MB-1 cTropnT-<0.01
___ 07:15AM BLOOD Calcium-9.6 Phos-3.5 Mg-2.1
Brief Hospital Course:
Mr. ___ is a ___ with history of hypertension, DVT with PEs
ultiple years ago, recent equivocal exercise stress test
Pesenting with chest paiN
#Chest Pain
Patient with recent positive exercise stress test with ischemic
changes concerning for CAD. However after the stress test, he
continued to have persistent chest pain at rest, which was mild
without any troponinemia or EKG changes. He had a cardiac
catheterization on ___ which revealed nonobstructive CAD.
Suspect that his chest pain at rest was likely secondary to
anxiety. He will continue medical management with aspirin and
atorvastatin.
TRANSITIONAL ISSUES
[]new medications: ASA 81mg, atorvastatin 40mg
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Cetirizine 10 mg PO DAILY
3. Potassium Chloride 40 mEq PO DAILY
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. saliva substitute combo ___ sprays mucous membrane TID
6. flaxseed oil unknown mg miscellaneous DAILY
7. garlic unknown mg oral DAILY
8. Glucosamine (glucosamine sulfate) unknown mg oral DAILY
9. salmon oil-omega-3 fatty acids 1,000-200 mg oral DAILY
10. Aspirin 81 mg PO DAILY
11. Tamsulosin 0.4 mg PO QHS
12. Ascorbic Acid Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Cetirizine 10 mg PO DAILY
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Potassium Chloride 40 mEq PO DAILY
6. saliva substitute combo ___ sprays mucous membrane TID
7. salmon oil-omega-3 fatty acids 1,000-200 mg oral DAILY
8. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Chest pain
Nonobstructive 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,
Why you were admitted?
-You were admitted because you were having chest pain.
What we did for you?
-You had a cardiac catheterization which revealed nonobstructive
coronary artery disease, which means that you have very mild
heart disease that does not need require any further
intervention.
-We suspect that your current chest pain may be more related to
anxiety.
What should you do when you leave the hospital?
-Please continue taking aspirin and atorvastatin, which will
assist with preventing any worsening heart disease.
-Please take all your other medications as prescribed.
-Please attend all your follow up appts
Followup Instructions:
___
|
10146904-DS-21 | 10,146,904 | 23,206,692 | DS | 21 | 2137-08-03 00:00:00 | 2137-08-05 13:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Vasotec
Attending: ___.
Chief Complaint:
Fall, shingles
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient was referred to the Emergency Department by ___ PCP
for chief complaint of shoulder pain and possible fracture and
shingles.
Per the ED, the patient is a ___ who lives in at nursing home.
Pt with recent fall, doesn't recall when. She isn't sure why she
is here or why she was taken here. Says that she is more
forgetful and doesn't recall recent events. Pt complaining of
left shoulder pain. Denies numbness, weakness, ha, neck/back
pain, cp, sob, n/v, abd pain. Spoke with niece, who says this
___ baseline MS. ___ nursing home provides good care." Nursing
in the Emergency Department reports she "fell either this
morning or yesterday morning. No LOC. Now c/o left shoulder
pain. Per nursing staff, rash present on back, ?shingles."
In the Emergency Department, initial vitals were 5 99.0 72
150/53 18 98% RA. The patient received IV ciprofloxacin 400mg,
along with 800mg PO acyclovir, and acetaminophen 1g. She is
admitted for anemia, zoster, urinary tract infection. ___ guaiac
was negative. On transfer, the patient's vital signs were 97.9
62 166/65 16 98%.
The patient is not a good historian due to forgetfulness. She
does believe that she had a fall, but denies any strike of head
or loss of consciousness. During my interview, she was denying
any shoulder pain. Instead, she only complained of itchiness in
___ left back. She denies any changes in ___ bowel habits or any
dark stools. She also denies any dysuria.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills. Denies headache, coryza symptoms.
Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation. No recent change in bowel or bladder habits. No
dysuria. Ten point review of systems is otherwise negative.
Past Medical History:
1. Chronic chest wall pain (likely costochondritis)
2. CAD - The patient's most recent stress test was on
___. No anginal type symptoms or ischemic ECG changes.
The rest and stress perfusion images revealed moderate fixed
perfusion defect in the base of the inferior wall. Gated images
revealed hypokinesis along the inferior wall. No new reversible
perfusion defects noted. LVEF of 60%. Previous PTCA of
occluded proximal RCA in ___ was deemed patent without
appreciable flow-obstruction during subsequent catheterization
in ___.
3. Memory issues - small vessel ischemic subcortical and
periventricular disease. Mild right frontal volume loss.
4. Gastroesophageal reflux disease
5. Diverticulitis
6. Hypothyroidism
7. History of breast cancer - The patient is status post
excisional biopsy significant for ___ infiltrating
ductal/papillary carcinoma with negative lymph nodes in the left
breast in ___. She did not tolerate Arimidex. She refused
radiation therapy.
8. Cervical spondylosis
9. Osteoarthritis of the spine
10. Osteopenia
11. Bilateral cataracts
12. Iron deficiency anemia secondary to GAVE
13. Mitral valve prolapse
14. Anemia with GAVE
PAST SURGICAL HISTORY:
1. Excisional biopsy of the left breast with lid negative lymph
node dissection - ___
2. Partial colectomy for treatment of diverticulitis - ___
3. Total abdominal hysterectomy and left salpingo-oophorectomy
4. Status post right hemiarthroplasty
Social History:
___
Family History:
The patient's father had hypertension and CAD. He died of an MI
in his late ___. ___ mother also had hypertension, CAD, but
lives at the age of ___. ___ sister died of lung cancer in ___
___.
Physical Exam:
Physical Exam on Admission:
Vitals: T: 97.6 BP: 164/68 P: 67 R: 99% O2: RA
General: Alert, orientedx3 but forgetful, no acute distress
HEENT: Sclera anicteric, MMM, false teeth, oropharynx clear
Neck: supple, no LAD, no carotid bruits
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Chest: On thoracic bcak has dermatomal clusters of vesicles at
varying stages of development with erythematous base around T10.
Stops at midline at spine. Patient additionally has erythematous
papules around T10 on left near sternum.
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, vertical scar from omphalos
downward
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: See above for description of vesicular clusters on chest.
Neuro: CNs ___ intact, ___ strength in all extremities, 2+
patellar reflexes.
Physical Exam on Discharge:
VITALS afebrile, RR 16, HR 60
CV: RRR
CTAB: Decreased breath sounds but no wet crackles
Skin: L T4 vesicular rash flat, all vesicles crusted over
Ext: No edema. R hand cleanly bandaged, edematous. Radial and
ulnar pulses 2+. Sensation intact. Full motor strength.
MS: Oriented to place, person and date. Much more alert with
insight into ___ hospitalization.
Pertinent Results:
ADMISSION LABS
--------------
___ 05:18PM BLOOD WBC-5.8 RBC-3.20* Hgb-7.7*# Hct-25.8*#
MCV-81*# MCH-24.2*# MCHC-30.0* RDW-16.3* Plt ___
___ 05:18PM BLOOD Ret Aut-1.3
___ 05:18PM BLOOD Glucose-105* UreaN-22* Creat-1.2* Na-135
K-3.7 Cl-102 HCO3-23 AnGap-14
___ 10:05PM BLOOD calTIBC-430 Ferritn-11* TRF-331
DISCHARGE LABS
--------------
___ 07:00AM BLOOD WBC-6.6 RBC-3.14* Hgb-7.4* Hct-24.6*
MCV-78* MCH-23.6* MCHC-30.1* RDW-16.7* Plt ___
___ 07:00AM BLOOD Glucose-82 UreaN-29* Creat-1.4* Na-137
K-4.1 Cl-107 HCO3-21* AnGap-13
___ 07:00AM BLOOD CK(CPK)-694*
MICROBIOLOGY
------------
URINE CULTURE (Final ___:
KLEBSIELLA OXYTOCA. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
KLEBSIELLA OXYTOCA
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING
-------
___ SHOULDER
IMPRESSION: Markedly abnormal left glenohumeral joint without
evidence of
acute fracture or new osseous abnormality.
___ (PA & LAT)
IMPRESSION: No acute cardiopulmonary process.
___ HEAD W/O CONTRAST
IMPRESSION:
1. No acute abnormality.
2. Aerosolized secretions in the left sphenoid sinus may suggest
sinusitis.
Please correlate clinically.
Brief Hospital Course:
___ F with dementia who presented with zoster, anemia and UTI
after un-witnessed fall at assisted living facility.
ACTIVE ISSUES
-------------
# Unwitnessed fall: She described a mechanical fall with no
head strike. Given that it was unwitnessed, we ruled out head
trauma with non contrast head CT, which showed no fracture or
hemorrhage. Telemetry showed no arrhythmias. On physical exam,
proprioception and gait were normal. Physical therapy cleared
___ to return to ___ assisted living facility.
# Herpes zoster: She presented with vesicles on erythematous
base across an L T5 dermatomal distribution. She also
complained of L sided pain and burning. We treated ___ with
Valacyclovir. Given ___ CKD (GFR 40 mL/min), she was put on a
reduced renal dose (1000mg BID, seven days). It was stopped
after only 4 days of therapy given that ___ rash had improved
(all vesicles crusted over) and out of concern for it being a
precipitant of ___ acute kidney injury.
# Altered mental status: She arrived forgetful, consistent with
___ baseline dementia (per niece). However, on the first night
of ___ hospitalization, she became agitated, threatening to
leave AMA, requiring haloperidol and 4 point restraints. ___
delerium was likely ___ UTI, ciprofloxacin, and disruption of
___ sleep/wake cycle. On subsequent nights, ___ agitation was
preempted by 12.5mg Seroquel at 7pm and d/c evening vital sign
checks. By ___ third day of hospitalization, ___ mental status
had improved back to baseline.
# Urinary tract infection: In the ED, ___ UA indicated a
urinary tract infection, which grew out Klebsiella sensitive to
ciprofloxacin. She completed a 3 day course of ciprofloxacin,
500mg BID.
# Acute kidney injury: She experienced pre-renal acute kidney
injury (Cre 1.1->1.5->1.7, FeUrea 25%) that improved with IVF
(Cre downtrended to 1.4). Urine sediment showed no casts or
crystals. f/u repeat Cre to confirm resolution of ___.
# Left shoulder pain: Left shoulder x-ray showed a stable
abnormal glenohumeral joint with no evidence of acute fracture
or new osseous abnormality. ___ pain was relieved with
acetaminophen, and we attributed ___ left shoulder pain to
muscle strain. ___ pain improved upon discharge.
# Iron deficiency anemia: She presented with a Hct of 25.8,
down from last measured Hct of 36.1 one year ago. Hemolytic
workup revealed non hemolytic, hypoproliferative anemia (0.4%).
Low ferritin (11) confirmed iron deficiency. She had guaiac
negative stools. ___ Hct remained stable throughout ___
admission, and we started ___ on ferrous iron supplements. She
should have a hematocrit check after discharge.
# CK elevation: She had a CK elevated to 996, concerning for
rhabdomyolysis ___ crush injury from ___ fall vs. myositis ___
simvastatin. We discontinued ___ simvastatin. By discharge,
___ CK downtrended to 694. She will require a follow-up of ___
CK and should possibly restart simvastatin once CK normalizes.
# Hypertension: She was originally orthostatic, with SBP
dropping from 120, sitting, to 100, standing. ___ orthostasis
improved with IV fluids, and resolved by discharge. However,
___ home medications of valsartan, nifedipine,
hydrochlorothiazide, and atenolol should be reconsidered if she
continues to complain of orthostasis.
# Hyperlipidemia: Simvastatin was stopped due to elevated CK.
She should possibly resume simvastatin once CK levels normalize.
INACTIVE ISSUES
---------------
# GERD: She received ___ home dose of pantoprazole in the
hospital. Continue Nexium at home.
TRANSITIONAL ISSUES
-------------------
Follow-up: appointment scheduled with Gerontology ___ at
12:00 ___.
Within ___ days post discharge, f/u appointment should also be
arranged with PCP for the following issues:
[1] Chem 7: confirm resolution ___ and return of Cre to
baseline (1.1).
[2] CK: confirm resolution of CK, restart Simvastatin if returns
to normal range
[3] UA: monitor resolution of UTI (Klebisella, treated with 3
days Ciprofloxacin)
[4] Herpes Zoster:: confirm resolution of L T4 dermatomal rash
[4] BP control: She arrived orthostatic (SBP 120->100 with
standing) that improved with IVF. Reconsider ___ beta blockers
and anti-hypertensives.
# CODE: Full code, confirmed with patient
# CONTACT: Patient's niece, ___, ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 25 mcg PO DAILY
2. NIFEdipine CR 60 mg PO DAILY
Hold for SBP < 100, HR < 60.
3. Hydrochlorothiazide 25 mg PO DAILY
Hold for SBP < 100.
4. Valsartan 160 mg PO DAILY
Hold for SBP < 100.
5. NexIUM *NF* (esomeprazole magnesium) 40 mg Oral Daily
6. Atenolol 50 mg PO BID
7. Donepezil 10 mg PO HS
8. Simvastatin 20 mg PO HS
9. Senna 1 TAB PO HS:PRN constipation
Discharge Medications:
1. Donepezil 10 mg PO HS
2. Senna 1 TAB PO HS:PRN constipation
3. Valsartan 160 mg PO DAILY
4. NIFEdipine CR 60 mg PO DAILY
5. Levothyroxine Sodium 25 mcg PO DAILY
6. Atenolol 50 mg PO BID
7. Ferrous Sulfate 325 mg PO DAILY iron deficiency
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
daily Disp #*15 Tablet Refills:*0
8. NexIUM *NF* (esomeprazole magnesium) 40 mg Oral Daily
9. Hydrochlorothiazide 25 mg PO DAILY
10. Outpatient Lab Work
Please check UA, creatinine and CK in ___ days
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Herpes Zoster (single dermatome)
Uncomplicated urinary tract infection (Klebsiella)
Acute kidney injury
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___. As you know, you were brought to our Emergency
Department due to your new rash and left shoulder pain
discovered after your fall at home. We took an xray of your
shoulder, which showed no acute fracture. A CT scan of your
head showed no acute bleeding in your head.
We believe your rash was shingles, which is a reactivation of a
common viral infection along a nerve root. In addition to being
itchy, shingles can be very painful, and we believe this
contributed to the L shoulder pain you were experiencing. We
treated you with antiviral medication (Valtrex). Your rash
improved and you are no longer on that medication. We also
found some bacteria in your urine, which we treated with a
different antibiotic, ciprofloxacin. Both your rash and urine
infection resolved, and you do not need to take these
medications at home.
During your hospitalization, you were also confused. We are
very happy to see that your confusion has greatly improved.
Your few days of confusion were likely due to your urinary tract
infection, and has resolved.
We stopped your Simvastatin given concern for muscle injury.
Make sure to follow up with your PCP to resume this medication
once your muscle injury resolves. It is also important for you
to follow up with your Gerontology appointment with Dr. ___ on
___.
It was a pleasure taking care of you at BI and we wish you a
safe trip back to ___ Home.
Sincerely,
___, ___ School Medical Student 4
Followup Instructions:
___
|
10146904-DS-23 | 10,146,904 | 22,169,828 | DS | 23 | 2138-06-07 00:00:00 | 2138-06-09 17:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Vasotec
Attending: ___.
Chief Complaint:
Chest pain, nausea, vomiting, and diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with history of CAD, chronic chest wall pain,
and Alzheimer's disease presenting from her assisted living
facility with reported chest pain, nausea, vomiting, and
diarrhea. Per report, there has been a recent viral
gastroenteritis outbreak at ___ facility. In the ED, pt was
noted to be afebrile on presentation with normal vital signs.
Labs were notable for a lack of leukocytosis, stable hct 30.4
(basline roughly 27), lactate 3.8, and a dirty UA. Pt received
1.5L of NS with improvement in lactate to 2.1. CXR did not
demonstrate an acute cardiopulmonary process, and CTA torso
demonstrated a fluid-filled bowel with minimally hyperenhancing
walls, suggestive of an inflammatory condition such as diffuse
mild enterocolitis. EKG demonstarted NSR with no evidence of
ischemia, and troponins were negative x 2. In addition to IV
fluids, pt received ciprofloxacin, zofran, morphine and atenolol
in the ED. However pt spiked one fever to 101, and was admitted
for further work up.
This AM, pt's VS were 99.7 116/43 56 18 97% on RA. Pt did not
know where she was or how she arrived at ___. She denies any
chest pain, nausea, vomiting or diarrhea. She denies any
urinary symptoms including pain with urination, difficulty
urinating, and suprapubic pain. Overall, she feels well.
Past Medical History:
1. Chronic chest wall pain (likely costochondritis)
2. CAD - The patient's most recent stress test was on
___. No anginal type symptoms or ischemic ECG changes.
The rest and stress perfusion images revealed moderate fixed
perfusion defect in the base of the inferior wall. Gated images
revealed hypokinesis along the inferior wall. No new reversible
perfusion defects noted. LVEF of 60%. Previous PTCA of
occluded proximal RCA in ___ was deemed patent without
appreciable flow-obstruction during subsequent catheterization
in ___.
3. Memory issues - small vessel ischemic subcortical and
periventricular disease. Mild right frontal volume loss.
4. Gastroesophageal reflux disease
5. Diverticulitis
6. Hypothyroidism
7. History of breast cancer - The patient is status post
excisional biopsy significant for her infiltrating
ductal/papillary carcinoma with negative lymph nodes in the left
breast in ___. She did not tolerate Arimidex. She refused
radiation therapy.
8. Cervical spondylosis
9. Osteoarthritis of the spine
10. Osteopenia
11. Bilateral cataracts
12. Iron deficiency anemia secondary to GAVE
13. Mitral valve prolapse
14. Anemia with GAVE
PAST SURGICAL HISTORY:
1. Excisional biopsy of the left breast with lid negative lymph
node dissection - ___
2. Partial colectomy for treatment of diverticulitis - ___
3. Total abdominal hysterectomy and left salpingo-oophorectomy
4. Status post right hemiarthroplasty
Social History:
___
Family History:
The patient's father had hypertension and CAD. He died of an MI
in his late ___. Her mother also had hypertension, CAD. Her
sister died of lung cancer in her ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS - 99.7 116/43 56 18 97% on RA
General: No apparent distress, lying comfortably in bed, pt is
oriented x 1, and cannot recall how or why she arrived at ___,
she does not know where she lives
HEENT: NCAT, PERRL, EOMI, OP clear, dry mucous membranes
Neck: JVP flat
CV: S1 S2 RRR no m/r/g
Lungs: CTAB no w/r/r
Abdomen: Soft, non-tender, no suprapubic tenderness,
non-distended, normoactive BS, no HSM
GU: deferred
Ext: No edema, clubbing, cyanosis
Neuro: ___ strength, SILT
Skin: No rashes
DISCHARGE PHYSICAL EXAM:
========================
VS - 98.8 126/65 P56-77 RR18 96%RA
General: Alert. Oriented x 1. NAD
HEENT: NCAT, PERRL, EOMI
Neck: Supple
CV: S1 S2 RRR no m/r/g
Lungs: CTAB no w/r/r
Abdomen: Soft, non-tender
Ext: No edema, clubbing, cyanosis
Pertinent Results:
ADMISSION LABS:
===============
___ 08:00AM BLOOD WBC-8.6 RBC-3.16* Hgb-9.7* Hct-30.5*
MCV-96# MCH-30.6# MCHC-31.7 RDW-15.6* Plt ___
___ 08:00AM BLOOD Neuts-92.6* Lymphs-4.5* Monos-1.9*
Eos-0.8 Baso-0.1
___ 08:00AM BLOOD Plt ___
___ 09:45AM BLOOD ___ PTT-30.4 ___
___ 08:00AM BLOOD Glucose-114* UreaN-22* Creat-1.4* Na-136
K-3.8 Cl-101 HCO3-19* AnGap-20
___ 08:00AM BLOOD ALT-12 AST-29 AlkPhos-67 TotBili-0.2
___:00AM BLOOD Lipase-42
___ 01:55PM BLOOD cTropnT-<0.01
___ 08:00AM BLOOD cTropnT-<0.01
___ 08:00AM BLOOD Albumin-3.9
___ 10:09AM BLOOD D-Dimer-524*
___ 08:04AM BLOOD Lactate-3.8*
___ 02:01PM BLOOD Lactate-2.1*
___ 10:52AM BLOOD Lactate-1.1
DISCHARGE LABS:
===============
___ 01:55PM BLOOD WBC-4.1 RBC-2.67* Hgb-8.2* Hct-25.5*
MCV-96 MCH-30.7 MCHC-32.1 RDW-16.0* Plt ___
___ 01:55PM BLOOD Plt ___
___ 01:55PM BLOOD Glucose-90 UreaN-25* Creat-1.4* Na-135
K-3.2* Cl-103 HCO3-23 AnGap-12
___ 01:55PM BLOOD Calcium-8.1* Phos-2.5* Mg-2.0
MICRO:
======
___ 3:48 pm URINE SOURCE: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
IMAGING:
========
Chest X-Ray AP ___
IMPRESSION: No acute cardiopulmonary abnormality.
CTA Chest/Abdomen/Pelvis ___
IMPRESSION:
1. No evidence of pulmonary embolism or other acute
cardiopulmonary process.
2. Fluid-filled bowel with minimally hyperenhancing wall,
suggestive of an inflammatory condition such as diffuse mild
enterocolitis.
3. Marked thinning and bulging of the right puborectalis muscle
with partial prolapse of the loewr rectum into the region of
diastasis, although non-obstructing. This appearance is not new
and is unlikely to relate to the current presentation although
it may be a possible source of symptoms related to the pelvic
floor.
Brief Hospital Course:
___ year old female with history of Alzheimer's disease
presenting with likely resolving viral gastroenteritis and
non-cardiac chest pain
ACUTE ISSUES:
=============
# Viral gastroenteritis: Pt presented from her assisted living
facility with reported nausea, vomiting, and diarrhea. Per
report, there had been a recent viral gastroenteritis outbreak
at ___ facility. In the ___ ED, pt was noted to be afebrile
on presentation with normal vital signs. Labs were notable for
a normal white count of 8.2, stable hct 30.4 (basline roughly
27), and lactate 3.8. Pt received 1.5L of NS with improvement
in lactate to 2.1. CXR did not demonstrate an acute
cardiopulmonary process, and CTA torso demonstrated a
fluid-filled bowel with minimally hyperenhancing walls,
suggestive of an inflammatory condition such as diffuse mild
enterocolitis consistent with viral gastroenteritis. Pt spiked
one fever to 101, and was admitted for further work up. On the
floor, pt did not spike any further, and had complete resolution
of her nausea, vomiting, and diarrhea. Pt will follow up with
her PCP ___.
# Chest pain: Per reports, pt presented with left sided chest
pain. In the ED, EKG demonstrated NSR with no evidence of
ischemia, and troponins were negative x 2. On arrival to the
medicine floor, pt's chest pain had resolved. Pt has a history
of chronic chest pain believed to be secondary to
costochondritis. This episode of chest pain was most likely a
combination of musculoskeletal and GERD
CHRONIC ISSUES:
===============
# HTN: On presentation, pt's anti-hypertensives were held in the
setting of hypovolemia due to vomiting, diarrhea and poor PO
intake. Pt's valsartan restarted prior to discharge with plans
for pt to follow up with her PCP ___ prior to restarting her
other home medications.
# Dementia: Continued home donepezil
# CAD: Held pt's atenolol and valsartan in the setting of
hypovolemia, and restarted prior to discharge.
# Hypothyroid: Continued home levothyroxine
# GERD: Pt was given esomeprazole in house, and restarted on
home omeprazole prior to discharge.
# Anemia: Pt presented with a stable chronic anemia.
TRANSITIONAL ISSUES:
====================
# Pt's home valsartan was restarted at discharge, and her other
antihypertensives were held. Pt will need a home BP check ___
with her ___.
# Pt will follow up with her PCP ___ at 10AM
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO BID
2. Donepezil 10 mg PO HS
3. Valsartan 160 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY iron deficiency
5. Levothyroxine Sodium 25 mcg PO DAILY
6. NIFEdipine CR 60 mg PO DAILY
7. NexIUM (esomeprazole magnesium) 40 mg Oral Daily
8. Chloraseptic Throat Spray 1 SPRY PO Q8H:PRN sore throat
9. Hydrochlorothiazide 25 mg PO DAILY
10. Acetaminophen 1000 mg PO BID:PRN pain
11. Senna 8.6 mg PO HS:PRN constipation
Discharge Medications:
1. Donepezil 10 mg PO HS
2. Levothyroxine Sodium 25 mcg PO DAILY
3. Valsartan 160 mg PO DAILY
4. Acetaminophen 1000 mg PO BID:PRN pain
5. Chloraseptic Throat Spray 1 SPRY PO Q8H:PRN sore throat
6. Ferrous Sulfate 325 mg PO DAILY iron deficiency
7. NexIUM (esomeprazole magnesium) 40 mg Oral Daily
8. Senna 8.6 mg PO HS:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
# Viral gastroenteritis
# Non-cardiac chest pain
SECONDARY DIAGNOSES:
# Hypertension
# Dementia
# Coronary artery disease
# Hypothyroidism
# Anemia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___,
___ was a pleasure taking care of you during your stay at ___.
You presented from your assisted living facility after
developing chest pain, nausea, vomiting and diarrhea. EKG and
labs demonstrated that you were not have a heart attack. In
addition, imaging of your abdomen showed some mild inflammation
of your intestines, consistent with a viral gastroenteritis.
You were given IV fluids for dehydration from vomiting and
diarrhea. You were restarted on your home antihypertensives
prior to discharge. Please follow up with your PCP ___ ___.
Followup Instructions:
___
|
10147499-DS-7 | 10,147,499 | 22,326,041 | DS | 7 | 2110-07-10 00:00:00 | 2110-07-30 15:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cervical stenosis
Major Surgical or Invasive Procedure:
1. Occiput to C2 decompression with a C1 laminectomy.
2. Occiput to C3 posterior arthrodesis.
3. Occiput to C3 posterior instrumentation.
4. Application of allograft and local autograft.
History of Present Illness:
___ female with remote history of cervical spine
fracture when she was ___ years old presenting today with neck
pain, paresthesias. Per the daughter and patient she's been
having worsening neck pain over her multiple weeks and started
to have worsening paresthesias in the arms and legs. She denies
any weakness in arms or legs. No bowel incontinence or bladder
retention. She denies any saddle anesthesia. She denies any
recent trauma.
Past Medical History:
htn, hyperlipidemia
Social History:
___ alone, upstairs from son. No ETOH, smokes ___
cigarettes daily. Uses wheelchair due to severe bilateral knee
arthritis.
Physical Exam:
AVSS
Well appearing, NAD, comfortable
BUE: SILT C5-T1 dermatomal distributions
BUE: ___ Del/Tri/Bic/WE/WF/FF/IO
BUE: tone normal, negative ___, 2+ symmetric DTR
bic/bra/tri
All fingers WWP, brisk capillary refill, 2+ distal pulses
BLE: SILT L1-S1 dermatomal distributions
BLE: ___ ___
BLE: tone normal, no clonus, toes downgoing, 2+ DTR knee/ankle
All toes WWP, brisk capillary refill, 2+ distal pulses
Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was transferred to the
PACU in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Foley was removed on POD#1. Physical
therapy was consulted for mobilization OOB to wheelchair. She
was able to demonstrate the ability to transfer independently
and operate the wheelchair. Hospital course was otherwise
unremarkable. On the day of discharge the patient was afebrile
with stable vital signs, comfortable on oral pain control and
tolerating a regular diet.
Medications on Admission:
Klonopin 0.25mg daily for anxiety
Simvastatin 10mg daily
diltiazem ER 180mg daily
losartan 100mg daily
metoprolol tartrate 25mg daily
aspirin 325 daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain
2. Aspirin 325 mg PO DAILY
3. Bisacodyl 10 mg PO/PR DAILY
4. ClonazePAM 0.5 mg PO QHS anxiety
5. Diltiazem Extended-Release 180 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Losartan Potassium 100 mg PO DAILY
8. Metoprolol Tartrate 25 mg PO DAILY
9. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4hours Disp #*90
Tablet Refills:*0
10. Simvastatin 10 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Chronic odontoid nonunion.
2. Severe spinal stenosis C1.
3. Cervical myelopathy.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You have undergone the following operation: Posterior Cervical
Decompression and Fusion
Immediately after the operation:
Activity: You should not lift anything greater
than 10 lbs for 2 weeks. You will be more comfortable if you do
not sit in a car or chair for more than ~45 minutes without
getting up and walking around.
Rehabilitation/ Physical Therapy:
___ ___ times a day you should go for a walk
for ___ minutes as part of your recovery. You can walk as
much as you can tolerate.
___ Isometric Extension Exercise in the
collar: 2x/day x ___xercises as
instructed.
Cervical Collar / Neck Brace: You need to wear
the brace at all times until your follow-up appointment which
should be in 2 weeks. You may remove the collar to take a
shower. Limit your motion of your neck while the collar is off.
Place the collar back on your neck immediately after the shower.
Wound Care: Remove the dressing in 2 days. If
the incision is draining cover it with a new sterile dressing.
If it is dry then you can leave the incision open to the air.
Once the incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain. . Please allow 72 hours for refill of
narcotic prescriptions, so please plan ahead. You can either
have them mailed to your home or pick them up at the clinic
located on ___ 2. We are not allowed to call in narcotic
prescriptions (oxycontin, oxycodone, percocet) to the pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Follow up:
___ Please Call the office and make an
appointment for 2 weeks after the day of your operation if this
has not been done already.
___ At the 2-week visit we will check your
incision, take baseline x rays and answer any questions.
___ We will then see you at 6 weeks from the
day of the operation. At that time we will most likely obtain
Flexion/Extension X-rays and often able to place you in a soft
collar which you will wean out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.
Physical Therapy:
WBAT BUE, BLE; c-collar at all times
Treatments Frequency:
Daily dry dressing change
Followup Instructions:
___
|
10147499-DS-8 | 10,147,499 | 23,722,759 | DS | 8 | 2110-07-30 00:00:00 | 2110-07-30 15:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
increase ___ weakness/numbness
Major Surgical or Invasive Procedure:
MRI
History of Present Illness:
Ms. ___ is a ___ yo F who underwent C2 decompression with
C1-C3 laminectomy/fusion on ___ w Dr ___, presents to ___
from rehab for increased ___ weakness and numbness. Ms. ___
is non-ambulatory in a wheelchair at baseline but reports noting
her ___ seemed weaker and were tingling when trying to transfer
to
her wheelchair today. She reports her left side seems weaker
than
her right. She also noted tingling below her knees - also left
worse than right. She denies any recent falls, trauma to the
___, or lower back pain. She has some neck discomfort but not
increasingly so. She has an appointment for a wound check with
Dr
___. Denies word finding difficulties, confusion,
bowel or bladder incontinence. Urinated normally twice today and
normal BM two day ago (her normal routine). Denies fevers,
chills, SOB, CP.
Past Medical History:
PMHx (per OMR and patient):
- Broke cervical vertebrae at ___, with C2 decompression on
___ C1-C3 laminectomy/fusion
- hypertension
- arthritis
- hyperlipidemia
- anxiety
Meds:
- Aspirin 325mg daily
- Bisacodyl 5mg tablet,delayed release daily
- Clonazepam 0.25mg BID
- Diltiazem ER 180mg capsule,extended release daily
- Losartan 100mg tablet daily
- Metoprolol tartrate 25mg daily
- Simvastatin 10mg qhs
- Oxycodone 5mg q3hrs PRN pain
- Melatonin 3mg qhs PRN insomnia
- Gabapentin 100mg TID
- OxyContin 10mg tablet,extended release BID
Allergies:
- NKDA
Social History:
___
Family History:
NC
Physical Exam:
Neck: incision well approximated, no errythema nor discharge, in
c-collar
Pulmonary: no increased WOB
Cardiac: RRR by palpation
Extremities: no edema, pulses palpated in ___ bilaterally; no
tenderness with palpation along ___ except appropriate
tenderness at surgical site.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ 5 4- ___- 4- 4-
R ___ ___ 5 4- 5 4+ 4 4 4
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 4 ___ beats)
R 3 3 3 3 4 ___ beats)
- Plantar response was extensor bilaterally..
-Sensory: sensation to light touch diminished to sharp and dull
touch below level of knees
Rectal: normal resting and active rectal tone and sensation
Brief Hospital Course:
admitted from ED for workup of new symptoms
CT scan demonstrated adequate fixation
MRI concern for C34 stenosis and severe lumbar stenosis
MRI repeated at C and L for better resolution than code cord
protocol
new MRI demonstrated stable myelomalacia at C1; C34 stenosis
moderate; lumbar stenosis present
exam improved
neurology consult following
patient tolerating PO
afebrile
vss
incision - sutures removed
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Diazepam 5 mg PO Q6H:PRN spasm/anxiety
RX *diazepam 2 mg ___ tablet(s) by mouth every six (6) hours
Disp #*60 Tablet Refills:*0
3. Diltiazem Extended-Release 180 mg PO DAILY
4. ClonazePAM 0.25 mg PO BID
5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
6. Docusate Sodium 100 mg PO BID
7. Losartan Potassium 100 mg PO DAILY
8. Metoprolol Tartrate 25 mg PO DAILY
9. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*100 Tablet Refills:*0
10. Simvastatin 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
odontoid nonunion and cervical stenosis s/p decompressive
surgery and Occipito-Cervical fusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You had undergone the following operation on prior admission:
Posterior Cervical Decompression and Fusion
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit in a car
or chair for more than ~45 minutes without getting up and
walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can
tolerate.
oIsometric Extension Exercise in the collar: 2x/day x ___xercises as instructed.
-Cervical Collar / Neck Brace: You need to wear the brace at
all times until your follow-up appointment which should be in 2
weeks. You may remove the collar to take a shower. Limit your
motion of your neck while the collar is off. Place the collar
back on your neck immediately after the shower.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry
then you can leave the incision open to the air. Once the
incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
-You should resume taking your normal home medications.
-You have also been given Additional Medications to control
your pain. . Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___. We are not allowed to call in narcotic prescriptions
(oxycontin, oxycodone, percocet) to the pharmacy. In addition,
we are only allowed to write for pain medications for 90 days
from the date of surgery.
-Follow up:
oPlease Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
oAt the 2-week visit we will check your incision, take baseline
x rays and answer any questions.
oWe will then see you at 6 weeks from the day of the operation.
At that time we will most likely obtain Flexion/Extension X-rays
and often able to place you in a soft collar which you will wean
out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.
Physical Therapy:
activity as tolerated
wheelchair transfer status preop
may stand with walker for safety
ambulation as tolerated
C collar full time - may remove for hygiene
Treatments Frequency:
keep incision clean and dry
may shower over incision
NO BATHS
pat dry
may cover with sterile gauze and tape
monitor incision for drainage, redness
Followup Instructions:
___
|
10147499-DS-9 | 10,147,499 | 27,547,361 | DS | 9 | 2110-08-02 00:00:00 | 2110-08-05 09:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F w/ hx of HTN, LHD and recent C2 decompression with
C1-C3 laminectomy/fusion on ___ who was sent in from rehab
facility due to altered mental status. Pt was in her usual state
of health until this morning when she was found to be confused.
Pt does promote feeling confused at the time. She and the
facility both deny a recent hx of fever, chills, or any
constitutional symptoms. She has been constipated and promotes
___ lower abdominal pain over this time. No hx of diarrhea. She
did have episode of hematuria yesterday but denies any dysuria
or increase freq. Denies any CP, lH, dizziness, or SOB. No pain
at surgical site. Denies any weakness. Continues to have b/l
lower extremity numbness which she says is her baseline and
unchanged.
In the ED, initial vitals were: 97.4 68 118/51 24 97%. She was
noted to be A&Ox3 but agitated. Labs were notable for UA with
pyuria, mod bacteria, large ___, blood, and nitrites. No
leukocytosis on CBC with stable H/H. Chem 7 notable for K+ of
5.5. A CT head was normal. CXR was normal. She was started on
CTX for UTI.
On the floor, she no longer feels confused and has no concerns.
She continues to promote mild lower abdominal/suprapubic
discomfort.
Past Medical History:
PMHx (per OMR and patient):
- Broke cervical vertebrae at ___, with C2 decompression on
___ C1-C3 laminectomy/fusion
- hypertension
- arthritis
- hyperlipidemia
- anxiety
Meds:
- Aspirin 325mg daily
- Bisacodyl 5mg tablet,delayed release daily
- Clonazepam 0.25mg BID
- Diltiazem ER 180mg capsule,extended release daily
- Losartan 100mg tablet daily
- Metoprolol tartrate 25mg daily
- Simvastatin 10mg qhs
- Oxycodone 5mg q3hrs PRN pain
- Melatonin 3mg qhs PRN insomnia
- Gabapentin 100mg TID
- OxyContin 10mg tablet,extended release BID
Allergies:
- NKDA
Social History:
___
Family History:
Non contributory
Physical Exam:
Admission:
Vitals: T:98.2 BP: 96/50 P: 80 R: 16 O2: 94% RA
General: Pt appears comfortable laying in bed A&Ox3
HEENT: NCAT, EOMI, ___, OMM with no lesions
Neck: No masses appreciated, collar in place. Surgical scar
healing without erythema.
CV: RRR, no m/r/g, no JVD
Lungs: CTABL with no r/w/r
Abdomen: TTP in suprapubic region, also ttp in RUQ with deep
palpation, no g/r. NO HSM. Bandage over lumbar spine c/d/i
GU: no foley in place
Ext: No edema, no rashes
Neuro: CN ___ grossly intact with ___ strength in all extm, no
focal deficits.
Skin: No rashes or ecchymosis appreciated
Vitals: T:98.7 BP: 121/75 P: 88 R: 16 O2: 94% RA
General: Pt appears uncomfortable sitting up in bed A&Ox3
HEENT: NCAT, EOMI, ___, OMM with no lesions
Neck: No masses appreciated, collar in place. Surgical scar
healing without erythema.
CV: RRR, no m/r/g, no JVD
Lungs: CTABL with no r/w/r
Abdomen: TTP in suprapubic region, also ttp in RUQ with deep
palpation, no g/r. NO HSM. Bandage over lumbar spine c/d/i
GU: no foley in place
Ext: No edema, no rashes
Neuro: CN ___ grossly intact with ___ strength in all extm, no
focal deficits.
Skin: No rashes or ecchymosis appreciated
Pertinent Results:
Admission:
___ 09:10AM BLOOD WBC-9.3 RBC-3.36* Hgb-10.8* Hct-32.7*
MCV-97 MCH-32.0 MCHC-32.9 RDW-12.9 Plt ___
___ 09:10AM BLOOD Neuts-84.7* Lymphs-10.1* Monos-3.9
Eos-0.9 Baso-0.4
___ 09:10AM BLOOD Glucose-102* UreaN-25* Creat-1.2* Na-136
K-7.5* Cl-102 HCO3-23 AnGap-19
___ 09:10AM BLOOD Calcium-8.4 Phos-4.3 Mg-2.4
Discharge:
___ 06:30AM BLOOD WBC-7.3 RBC-3.00* Hgb-9.4* Hct-28.9*
MCV-96 MCH-31.4 MCHC-32.6 RDW-13.2 Plt ___
___ 06:30AM BLOOD Neuts-82.3* Lymphs-13.7* Monos-2.9
Eos-1.0 Baso-0.1
___ 06:30AM BLOOD Glucose-109* UreaN-19 Creat-0.9 Na-137
K-3.9 Cl-101 HCO3-22 AnGap-18
___ 06:30AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.1 Iron-PND
Imaging:
CXR:
IMPRESSION:
Minimal left basilar atelectasis.
CT Head:
IMPRESSION:
No evidence of acute intracranial abnormality. MRI is more
sensitive in the detection of acute stroke.
Brief Hospital Course:
___ yo F with a history of HTN, hyperlipidemia and recent C2
decompression with C1-C3 laminectomy/fusion on ___ who was sent
in from rehab facility due to altered mental status and was
found to have urinary tract infection.
# Altered mental status: Patient presented with AMS which
resolved by the time of admission. Most likely secondary to
urinary tract infection and large doses of narcotics and
diazepam following surgery. Patient remained A&Ox3 entire
admission. Previously prescribed oxycodone was discontinued and
she was transitioned to standing tylenol with as needed
tramadol. She will also use ibuprofen as needed on a full
stomach. The risk of NSAIDS were discussed with patient but she
notes they offer the greatest relief. She was guaiac negative
this admission. Hematocrit should be monitored closely while
taking this medication. Patient should not take aspirin while
taking NSAIDS.
#UTI: Urine analysis was strongly suggestive of infection with
moderate bacteria and large ___ and nitrites. Urine culture grew
pansensitive entercocci. She was treated with a 7 day ___ of
amoxacillin for sensitive enterococcus. Infection most likely
secondary to foley placements during recent hospitalizations.
#Hx of C2 decompression with C1-C3 laminectomy/fusion: Incision
appeared clean and without signs of infection. Patient noted
extreme discomfort with ___ j collar. She was evaluated by
orthopedics who arranged for a new, smaller collar. Patient's
pain regimen was modified this admission by holding oxycodone
and adding tramadol due to AMS. She will also take ibuprofen as
needed (risks and side effects discussed). She will continue to
follow up with ortho as an outpatient. Patient deferred going
back to a rehab facility and will continue ___ at home.
#Weakness: Rehab facility noted weakness prior to admission but
patient found to have ___ strength on exam without focal
deficits. Neuro evaluated earlier this week without concern. MRI
without new findings.
#Anemia: Most likely secondary to chronic disease with high
ferritin and low TIBC. Guaiac negative this admission. Has been
downtrending over the last several admissions and should be
monitored going forth. Recommend outpatient hematocrit within
the next ___ days to ensure stability.
CHRONIC ISSUES MANAGED:
#HTN: continued home losartan and metoprolol.
#Hyperlipidemia: Continued with home simvastatin
#Anxiety: continued with home clonazepam .25mg BID
Transitions of Care:
#Patient chose to go home and not back to rehab. She will have
home services and ___.
#She developed a stage II sacral pressure ulcer at rehab which
will need close monitoring and pt will need frequent turning.
# Patient will take ibuprofen as needed for pain as she notes
this works the best for her. She should be closely monitored for
bleeding.
#She will complete a 7 day course of bactrim as an outpatient
#Full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H
2. Diazepam 5 mg PO Q6H:PRN spasm/anxiety
3. Diltiazem Extended-Release 180 mg PO DAILY
4. ClonazePAM 0.25 mg PO BID
5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
6. Docusate Sodium 100 mg PO BID
7. Losartan Potassium 100 mg PO DAILY
8. Metoprolol Tartrate 25 mg PO DAILY
9. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN Pain
10. Simvastatin 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. ClonazePAM 0.25 mg PO BID
4. Diltiazem Extended-Release 180 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Losartan Potassium 100 mg PO DAILY
7. Metoprolol Tartrate 25 mg PO DAILY
Hold for HR <60, Systolic blood pressure <100
8. Simvastatin 10 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Urinary Tract Infection
Toxic Metabolic Encephalopathy
Stage 1 Sacral decubitus
Secondary Diagnosis
Status Post C1-C3 laminectomy/fusion
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 ___
___. You were brought in for increasing confusion and
weakness. We believe this was due to a urinary tract infection
in addition to the pain medications you were taking. You were
started on antibiotics which you will continue to take at hpme.
Your pain medication regimen was also modified.
You have decided to go home and not back to rehab. Your PCP ___
follow up with you at home this coming week.
Followup Instructions:
___
|
10147525-DS-18 | 10,147,525 | 26,112,986 | DS | 18 | 2148-01-14 00:00:00 | 2148-01-14 17:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Abilify / nicotine
Attending: ___.
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
History of Present Illness:
Ms. ___ per patient, is a ___ year old
female with reported PMH of schizophrenia, hypertension, who
presents via EMS for cough. Unable to obtain full history due to
encephalopathy. Patient knows that she is at "an extension of
___ but when asked what brings her to the hospital,
patient states, "I slept every night", "I was sitting on the
floor" and "A woman did this." Per EMS note, patient did report
a cough for the last 3 days with associated mild chest pain. She
denies both of these currently. She does state she vomited twice
at home and has stomach pain, but is unable to further qualify
this. When asked about fevers, recalls that she had one in the
ED, and denies any at home.
No further records are currently available. On review of
___, patient is taking clonazepam 2mg daily and gabapentin
400mg BID. These are prescribed most recently by Dr. ___
___, a psychiatrist associated with ___
at ___ and ___ family medicine NP at
___. She also filled prescriptions in ___ that
were prescribed by ___. In the ED, initial
vitals: T 103, HR 92, BP 145/58, RR 30, 100% 2L NC
Labs were significant for
- CBC: WBC 12.4 (90% n), hgb 13.8, Plt 321
- LFTs: AST: 127 ALT: 110 AP: 219 Tbili: 1.5 Alb: 4.1
- trop <0.01
- lactate 3.6 -> 3.4 following 1L IVF
- flu swab negative
- serum and urine tox negative
- RUQUS with mild intrahepatic biliary ductal dilation. No
extrahepatic biliary ductal dilation. In the presence of
cholelithiasis, these findings could reflect partially
obstructing or recently resolved choledocholithiasis
Vitals prior to transfer: HR 81, BP 118/53, RR 19, 98% 2L NC
Currently, patient remains confused. She is oriented to "an
extension ___ but not to time. She answers direct
questions, though not always with appropriate answers. She is
nauseous currently, asking for a bucket. ROS: Limited due to
encephalopathy. To direct questioning, notes no fevers at home,
currently denying cough and chest pain (previous endorsed). Does
report abdominal pain and nausea/vomiting, no diarrhea.
Past Medical History:
- schizophrenia
- hypertension
- chronic back pain
Social History:
___
Family History:
unable to obtain ___ encephalopathy
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 98.4, HR 77, BP 100/65, RR 18, 97% 2L
GENERAL: Confused, lying on side in bed, attempting to vomit at
times, not always answering appropriately
EYES: Anicteric, pupils equally round and reactive to light,
~4mm
bilaterally
ENT: Left lower lip swollen, patient biting it at times. Ears
and
nose without visible erythema, masses, or trauma. Oropharynx
without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: No increased work of breathing. Bilateral scattered
rhonchi
and wheezing
GI: Abdomen soft, moderately distended, acutely tender to
palpation in RUQ. Bowel sounds present but diminished. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, Lower extremities cool
but with 2+ DP pulses bilaterally, no edema
SKIN: No rashes or ulcerations noted
NEURO: Lethargic, arousable to voice. Oriented to self and
place,
not to situation or time. PERRL, EOMI. Reports symmetric
sensation on face. Left lip swelling initially appears to be
facial droop, but symmetric smile and closes eyes symmetrically.
Hearing grossly intact. Does not shrug or turn head despite
multiple prompts. Upper proximal strength ___ on right, 4+/5 on
left - distal strength ___ bilaterally, and sensation to light
touch intact. Proximal and distal strength of lower extremities
___ bilaterally. Able to do finger-nose-finger bilaterally,
though slowly
DISCHARGE PHYSICAL EXAM:
=======================
VS: T99 BP 116/66 HR 85 RR18 94%RA
HEENT: NC/AT, possible slight NLFF on the L, face otherwise
symmetric
Cardiovascular: RRR
Pulmonary: diminished at bases, otherwise CTA b/l.
Gastroinestinal: S/NT/ND, BS present
Skin: No rashes or ulcerations are evident
Ext: trace edema bilaterally.
Neurological: Ox3, no pronator drift, ___ strength in all 4
extremities
Psychiatric: calm, flat affect
Pertinent Results:
ADMISSION LABS:
===============
___ 09:45PM BLOOD WBC-12.4* RBC-4.61 Hgb-13.8 Hct-41.6
MCV-90 MCH-29.9 MCHC-33.2 RDW-13.0 RDWSD-42.4 Plt ___
___ 09:45PM BLOOD Neuts-90* Bands-0 Lymphs-4* Monos-6 Eos-0
Baso-0 ___ Myelos-0 AbsNeut-11.16* AbsLymp-0.50*
AbsMono-0.74 AbsEos-0.00* AbsBaso-0.00*
___ 09:45PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 09:45PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 09:45PM BLOOD ___ PTT-31.0 ___
___ 09:45PM BLOOD Glucose-126* UreaN-11 Creat-1.0 Na-133*
K-3.7 Cl-84* HCO3-31 AnGap-18
___ 09:45PM BLOOD ALT-110* AST-127* AlkPhos-219*
TotBili-1.5
___ 09:45PM BLOOD Lipase-22
___ 09:45PM BLOOD cTropnT-<0.01
___ 09:45PM BLOOD Albumin-4.1 Calcium-10.1 Phos-2.7 Mg-1.5*
IMAGING:
========
CXR ___ - IMPRESSION:
Retrocardiac opacity likely atelectasis though difficult to
exclude pneumonia
in the correct clinical setting. Mild right basal atelectasis.
RUQ US ___ - IMPRESSION:
1. Mild intrahepatic biliary ductal dilation. No extrahepatic
biliary ductal
dilation. In the presence of cholelithiasis, these findings
could reflect
partially obstructing or recently resolved choledocholithiasis.
Consider
MRCP.
2. Cholelithiasis. No cholecystitis.
3. Mild splenomegaly measuring 14 cm.
CT Head ___ - IMPRESSION:
No evidence of an acute intracranial abnormality.
ERCP ___ - IMPRESSION:
1. No acute intracranial abnormality on noncontrast head CT.
Specifically no
acute large territory infarct or intracranial hemorrhage.
2. 5 mm basilar tip aneurysm. The left SCA appears to arise
from the neck of
the aneurysm. The remainder of the CTA head is unremarkable
allowing for
suboptimal contrast bolus timing.
3. Allowing for mild atherosclerotic disease, unremarkable CTA
of the neck
allowing for suboptimal contrast bolus timing. There is no
stenosis of the
internal carotid arteries by NASCET criteria.
4. Additional findings as described above.
CXR ___ - IMPRESSION:
Heart size and mediastinum are stable. There is mild vascular
congestion but
no overt pulmonary edema. There is no appreciable
consolidation. There is
minimal amount of small bilateral pleural effusion. S/p
thoracic vertebral
surgery.
CXR ___ - IMPRESSION:
Compared to chest radiographs ___.
Small right pleural effusion and mild bibasilar atelectasis
worsened slightly
since ___. Upper lungs clear. Heart size normal. No
pneumothorax.
TTE ___ - IMPRESSION: Normal biventricular cavity sizes,
regional/global systolic function. Mild mitral regurgitation
with normal valve morphology. Mild pulmonary artery systolic
hypertension.
LABS AT DISCHARGE:
=================
___ 07:30AM BLOOD WBC-6.5 RBC-4.02 Hgb-11.8 Hct-37.9 MCV-94
MCH-29.4 MCHC-31.1* RDW-14.1 RDWSD-49.2* Plt ___
___ 07:30AM BLOOD Glucose-102* UreaN-9 Creat-0.9 Na-143
K-3.8 Cl-100 HCO3-34* AnGap-9*
Brief Hospital Course:
___ with schizophrenia presented with cough and encephalopathy
in the setting of cholangitis now s/p ERCP with stent placement.
Patient deferring CCY to later date. Course complicated by
persistent hypoxemia and possible subacute CVA.
# Sepsis, severe, due to cholangitis:
s/p ERCP on ___, which demonstrated multiple biliary stones
and frank pus, now s/p stent placement and sphincterotomy. Pt
was treated with cefepime/flagyl x 7 days. She will need repeat
ERCP in 6 weeks for stent removal (to be arranged by ERCP). She
opted to defer CCY until after discharge. This will need to be
discussed at follow up. Due to significant deconditioning, she
will require rehab for ongoing physical therapy.
# Hypoxemia:
Repeat CXR on ___ with vascular congestion but no overt edema,
no consolidation. Mild effusions. Repeat CXR ___ with
persistent small right effusion and atelectasis, but no focal
consolidation nor significant edema. proBNP mildly elevated.
Hypoxemia attributed to atelectasis and mild volume overload in
setting of IVF resuscitation during sepsis. She is been diuresed
with IV Lasix. TTE showing normal systolic function with mild
pulmonary hypertension. Despite diuresis as above, she had
persistent O2 requirement. Pulm evaluated her and felt likely
multifactorial, including component of ongoing mild volume
overload as well as likely underlying emphysema. She has since
been weaned off of O2. She was started on spiriva. Pulm follow
up is being coordinated at the time of discharge.
# Episode of left facial droop, pronator drift:
# Concern for possible subacute CVA:
# Incidentally discovered 5mm aneursym:
Code stroke called ___ with NIHSS of 3 and CTA head and neck
without hemorrhage or LVO. No TPA given. Initially low concern
for acute CVA per neurology but given persistence of left
weakness, cannot exclude lesion affecting the right corona
radiata or internal capsule. Recommended MRI, but patient
refusing due to severe claustrophobia. She was offered ASA and
statin for possible secondary prevention, but patient declined.
Neurosurgery consulted for aneurysm and recommended outpatient
followup. At time of discharge, no definitive conclusion from
Neurology if patient truly had a stroke, would need MRI for
confirmation.
# Schizophrenia:
Home meds held in setting of TME on presentation, resumed once
stable.
# HTN:
- holding home BP meds as patient normotensive without.
TRANSITIONAL ISSUES:
====================
[] New meds: Spiriva
[] Ensure patient has outpatient pulmonary follow up for ongoing
workup of suspected obstructive lung disease.
[] will require ERCP follow up for removal of biliary stent.
[] Need to revisit recommendation for outpatient CCY for
definitive management of gallstones.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 400 mg PO BID
2. ClonazePAM 2 mg PO QHS
3. Propranolol 10 mg PO BID
4. Omeprazole 20 mg PO BID
5. Potassium Chloride 10 mEq PO BID
6. OLANZapine 25 mg PO QHS
7. Hydrochlorothiazide 25 mg PO DAILY
8. Vitamin D 5000 UNIT PO DAILY
Discharge Medications:
1. Tiotropium Bromide 1 CAP IH DAILY
2. ClonazePAM 2 mg PO QHS
RX *clonazepam 2 mg 1 tablet(s) by mouth at bedtime Disp #*10
Tablet Refills:*0
3. Gabapentin 400 mg PO BID
RX *gabapentin 400 mg 1 capsule(s) by mouth twice a day Disp
#*20 Capsule Refills:*0
4. OLANZapine 25 mg PO QHS
5. Omeprazole 20 mg PO BID
6. Propranolol 10 mg PO BID
7. Vitamin D 5000 UNIT PO DAILY
8. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication was
held. Do not restart Hydrochlorothiazide until discussed with
PCP.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
cholangitis with severe sepsis and encephalopathy
possible subacute stroke
emphysema
pulmonary edema
schizophrenia
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a privilege to care for you at the ___. You were
admitted with an infection in your bile ducts. You underwent a
procedure called and ERCP, and you were treated with
antibiotics. Additionally, your oxygen levels were noted to be
low while you were here. This was felt to be due to a
combination of fluids you received for your infection as well as
underlying lung disease related to smoking. Luckily you have
been weaned off oxygen. We are working to arrange a follow up
appointment with a lung doctor to further assess your breathing.
Additionally, you will need to follow up with the GI doctors to
have your biliary stent removed as well as the Neurosurgeons for
ongoing monitoring of your incidentally discovered aneurysm.
Please take all medications as prescribed and follow up with the
appointments as listed below.
We wish you the best!
Sincerely,
Your ___ team
Followup Instructions:
___
|
10147617-DS-18 | 10,147,617 | 22,981,794 | DS | 18 | 2131-12-11 00:00:00 | 2131-12-23 15:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Trauma/Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This patient is a ___ year old male who complains of s/p
Fall. He was shoveling a roof, fell 8 feet and landed on his
back. No LOC. Complains of right lower back pain and
posterior rib pain.
Past Medical History:
HTN, GERD, spinal fusion
Social History:
___
Family History:
Non contributory
Physical Exam:
GENERAL: NAD A&Ox3
HEENT: NCAT
HEART: RRR
LUNGS: CTA, TTP over R hemichest
BACK: deferred
ABD: soft
MSK/EXT: MAE, dressed abrasion over R elbow
Pertinent Results:
CHEST:
The thyroid is normal. No axillary, supraclavicular,
mediastinal, or hilar
lymph node enlargement by CT size criteria. The great vessels
are
unremarkable. The heart and mediastinum are normal. No
pericardial effusion.
The airways are patent to the subsegmental level.An air-fluid
level is noted
within the mid esophagus increasing risk for aspiration. A small
right
pneumothorax is present. No mediastinal shift. Bilateral lower
lobe
atelectasis is present. Ground-glass opacities within the right
lower lobe
along its dependent portion is most consistent with atelectasis
however
differential includes pneumonia and aspiration. A small right
pleural effusion
is of higher density worrisome for small hemorrhagic pleural
effusion. No
obvious extravasation of IV contrast.
ABDOMEN:
The liver is homogeneous. A 1.4 x 1.8 cm (02:56) hypodensity is
seen adjacent
to the gallbladder fossa and is incompletely characterize,
potentially a
hemangioma. No intra or extrahepatic biliary duct dilatation.
The portal vein,
SMV, and splenic vein are patent. The gallbladder, pancreas,
spleen, and
bilateral adrenal glands are normal. The kidneys enhance
symmetrically and are
without suspicious solid mass. No perinephric fluid collection.
The stomach is normal. The small and large bowel are
unremarkable without
dilation or wall thickening. The appendix is normal without
evidence of acute
appendicitis. The aorta is normal in caliber without aneurysmal
dilatation.
No retroperitoneal hematoma. The celiac axis, SMA,and ___ are
patent. No
retroperitoneal or mesenteric lymph node enlargement. No free
abdominal fluid,
abdominal wall hernia or pneumoperitoneum. An approximately 11
x 2.7 cm
(2:85) right sided hematoma is seen superior to the gluteal
muscles along the
right paraspinal muscles with associated fat stranding. An
additional 5.9 x 3
cm (2:117) hematoma is seen adjacent to the right greater
trochanter.
PELVIS:
The bladder is well distended and unremarkable. No pelvic
side-wall or
inguinal lymph node enlargement. No free pelvic fluid seen.
Small amount of
fat is seen along the left spermatic cord.
OSSEOUS STRUCTURES: Right rib fractures spanning third through
11th ribs
posterorlaterally with displacement of the ___ and 9 rib
fractures. Fractures
at the medial aspect of the fifth through tenth ribs adjacent to
the
costovertebral junction are noted. Small amount of subcutaneous
emphysema is
seen posterior to the eleventh and tenth ribs. Spinal fusion
device spanning
L4 through S1 is present. Multilevel degenerate changes
throughout the
thoracolumbar spine most notable at T9-10 and L1-L2. No focal
lytic or
sclerotic lesion concerning for malignancy.
IMPRESSION:
1. Small right pneumothorax without mediastinal shift.
2. Ground-glass opacity in the right lower lobe is most
consistent
atelectasis however differential includes pneumonia and
aspiration in the
appropriate clinical setting.
3. Small right hemorrhagic pleural effusion. No definite
evidence of active
extravasation.
4. Multiple right-sided displaced and nondisplaced rib
fractures spanning
third through eleventh ribs as described above. Fifth through
tenth
right-sided rib fractures are segmental.
5. 11 cm right-sided hematoma superior to right gluteal muscles
along the
right paraspinal muscles as well as 5.9 cm hematoma adjacent to
right greater
trochanter.
6. Fluid-filled esophagus increasing risk for aspiration.
No cervical spine fracture or acute malalignment. Vertebral body
and disc
height are preserved. Multilevel degenerative changes are noted
atC5-C6. Pre
and paravertebral soft tissues are normal. Visualized portions
of the
skullbase show no abnormalities.
Limited assessment of the spinal canal is notable for mild canal
narrowing at
T2 by ligamentum flavum hypertrophy and calcification.
Visualized portions of
the aerodigestive tract are patent. Limited assessment of the
lung apices is
notable for a lucency along the right lung apices consistent
with a small
apical pneumothorax.
IMPRESSION:
1. Small right apical pneumothorax.
2. No cervical spine fracture or malalignment
No evidence of hemorrhage, edema, mass effect, or acute large
territorial
infarction.The ventricles and sulci are normal in size and
configuration.
The basal cisterns are patent and there is preservation of
gray-white matter
differentiation.
No fracture identified. The visualized paranasal sinuses,
mastoid air cells,
and middle ear cavities are clear. The globes are unremarkable.
IMPRESSION:
Normal head CT, specifically no hemorrhage.
Brief Hospital Course:
Mr. ___ was admitted to ___ following a fall from 8 feet. He
was found to have multiple right side rib fractures and a
gluteal hematoma. However, during his stay, he had a difficulty
with pain control. He was evaluated by the acute/chronic pain
services. He continued to improve with continued pain control.
He had no acute issues while an inpatient. His pneumothorax was
monitored with daily chest xrays with no progression. HE was
discharged home on ___ with follow up. At the time of discharge
he was doing well, he was voiding, tolerating PO, and ambulating
independently
Medications on Admission:
Suboxone ___ BID
Trazadone 50mg prn QHS
Celexa 20mg daily
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
4. Morphine Sulfate ___ 20 mg PO Q4H:PRN pain
RX *morphine 20 mg 1 capsule(s) by mouth every 4 hours Disp #*84
Capsule Refills:*0
5. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
7. Pregabalin 75 mg PO BID
RX *pregabalin [Lyrica] 75 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
8. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*60
Capsule Refills:*0
9. Simethicone 40-80 mg PO QID:PRN gas pain
10. TraZODone 50 mg PO QHS:PRN insomnia
11. Tizanidine 4 mg PO BID
RX *tizanidine 2 mg 2 capsule(s) by mouth twice a day Disp #*30
Capsule Refills:*0
1. Acetaminophen 1000 mg PO Q6H
2. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
4. Morphine Sulfate ___ 20 mg PO Q4H:PRN pain
RX *morphine 20 mg 1 capsule(s) by mouth every 4 hours Disp #*84
Capsule Refills:*0
5. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
7. Pregabalin 75 mg PO BID
RX *pregabalin [Lyrica] 75 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
8. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*60
Capsule Refills:*0
9. Simethicone 40-80 mg PO QID:PRN gas pain
10. TraZODone 50 mg PO QHS:PRN insomnia
11. Tizanidine 4 mg PO BID
RX *tizanidine 2 mg 2 capsule(s) by mouth twice a day Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right ___ rib fracture, small apical Right pneumothorax, right
gluteal hematoma, 8mm right elbow laceration
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 after a fall. You suffered
multiple injuries which are now resolved or are resolving. You
were followed by the ACS service and chronic pain service for
your injuries. You are now doing well and you are ready to
return home.
* Your injury caused multiple rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
10147782-DS-15 | 10,147,782 | 26,174,094 | DS | 15 | 2183-01-16 00:00:00 | 2183-01-16 14:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Right groin pain
Major Surgical or Invasive Procedure:
Right femoral hernia repair and repair of enterotomy
History of Present Illness:
Ms. ___ is an ___ ___
female with PMH including A. fib on Eliquis, dementia,
hypertension, type 2 NSTEMI who presents to the ___ medical MC
ED
with abdominal pain and a palpable bulge in the right groin,
both
of which were first noticed to have started at 4:30 ___
yesterday. Her daughter notes no prior history of any similar
bulges or similar symptoms, and she has never been diagnosed
with
a hernia in the past. Her pain has been generalized across the
entirety of the abdomen. It was associated with abdominal
distention and one episode of emesis yesterday of bilious brown
fluid, currently her nausea is relatively mild. It has not been
associated with fevers, chest pain, shortness of breath. Due to
the patient's history of dementia it is difficult to determine
her last bowel movement or flatus, however her daughter states
that she has not had any recent bowel movements since coming
home
from her senior care center yesterday and has not noticed any
flatus. She does have known chronic constipation.
Of note, she is maintained on Eliquis for her atrial
fibrillation; her last dose was yesterday morning just short of
24 hours ago. She also reports resolved but recent cold
symptoms
and as part of those she had multiple bouts of intense coughing
and presumably straining as well.
Past Medical History:
Past Medical History:
Hypertension, atrial fibrillation, dementia, type II NSTEMI
Past Surgical History:
None
Social History:
___
Family History:
Noncontributory
Physical Exam:
Vitals:
T 97.5 BP 160 / 74 HR 65 RR 18 O2 saturation 99% on room air
Gen: Alert, no acute distress
HEENT: Midline trachea
CV: Heart regular rate and rhythm
Pulm: Breathing unlabored on room air
Abdomen: soft, nontender, nondistended. Right groin incision
approximated and covered with dermabond. No erythema or
drainage. Small area of nonblanching rubor on the mons pubis.
Ext: Warm and well perfused
Pertinent Results:
Final Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with RLQ abdominal
pain and
productive coughNO_PO contrast// CT: hematoma? hernia?/ PNA on
CXR
TECHNIQUE: Single phase split bolus contrast: MDCT axial images
were acquired
through the abdomen following intravenous contrast
administration with split
bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy
(Body) DLP =
9.6 mGy-cm.
2) Spiral Acquisition 5.3 s, 41.6 cm; CTDIvol = 9.6 mGy
(Body) DLP = 400.3
mGy-cm.
3) Spiral Acquisition 1.1 s, 8.6 cm; CTDIvol = 6.9 mGy (Body)
DLP = 59.5
mGy-cm.
4) Spiral Acquisition 1.2 s, 9.1 cm; CTDIvol = 6.9 mGy (Body)
DLP = 63.2
mGy-cm.
Total DLP (Body) = 533 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits.
There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: 2.2 x 1.6 cm hyperenhancing lesion within the
right lobe of the
liver, likely a hemangioma. Additional subcentimeter
hypodensities within the
liver too small to characterize, likely represent cysts or
biliary hamartomas.
Otherwise, the liver demonstrates homogenous attenuation
throughout. There is
no evidence of intrahepatic or extrahepatic biliary dilatation.
The
gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal lesions or pancreatic ductal dilatation. There is no
peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis.
There is no
perinephric abnormality.
GASTROINTESTINAL: There are multiple dilated loops of small
bowel with
air-fluid levels, compatible with small bowel obstruction. The
transition
point is a right femoral hernia with compression of the right
common femoral
vein. There is no bowel wall thickening. There is no
pneumatosis. There is
no free air or fluid. The stomach is unremarkable. The colon
and rectum are
within normal limits. The appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are
unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate
atherosclerotic
disease is noted, particularly within the proximal SMA with
moderate to severe
stenosis (series 602, image 37).
BONES: Degenerative changes throughout the lumbar spine with
moderate
dextroconvex scoliosis. Mild retrolisthesis of L3 on L4. There
is no
evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: There is a right femoral hernia containing
obstructed loops of
small bowel. There is a small fat containing left inguinal
hernia.
IMPRESSION:
1. Small-bowel obstruction due to a right femoral hernia with
compression of
the right common femoral vein. No bowel wall thickening,
pneumatosis, or
pneumoperitoneum.
2. Moderate atherosclerosis with moderate to severe stenosis of
the proximal
SMA.
3. 2.2 cm liver hemangioma.
___ 07:43AM BLOOD WBC-13.0* RBC-3.22* Hgb-9.4* Hct-28.6*
MCV-89 MCH-29.2 MCHC-32.9 RDW-14.6 RDWSD-47.2* Plt ___
___ 09:45AM BLOOD WBC-10.8* RBC-3.34* Hgb-9.9* Hct-30.0*
MCV-90 MCH-29.6 MCHC-33.0 RDW-15.0 RDWSD-49.2* Plt ___
Brief Hospital Course:
The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of groin bulge and pain.
Admission CT abdomen/pelvis revealed an incarcerated right
femoral hernia. The patient underwent open repair of her hernia
and repair of an enterotomy, which went well without
complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor NPO on IV fluids, and with adequate
pain control. 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 with the assistance of her
daughters, 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. On postoperative day 2, her home eliqiuis
was restarted without issue.
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,
where she lives with her daughter. The patient and her family
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. lisinopril-hydrochlorothiazide ___ mg oral DAILY
2. benzonatate 100 mg oral TID
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Senna 17.2 mg PO BID:PRN Constipation - First Line
6. Memantine 5 mg PO BID
7. Apixaban 2.5 mg PO BID
8. Atorvastatin 40 mg PO DAILY
9. melatonin 3 mg oral DAILY
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. Omeprazole 20 mg PO DAILY
12. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours as
needed Disp #*30 Tablet Refills:*0
2. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
3. Apixaban 2.5 mg PO BID
4. Atorvastatin 40 mg PO DAILY
5. benzonatate 100 mg oral TID
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily as
needed Disp #*30 Capsule Refills:*0
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. lisinopril-hydrochlorothiazide ___ mg oral DAILY
9. melatonin 3 mg oral DAILY
10. Memantine 5 mg PO BID
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Senna 17.2 mg PO BID:PRN Constipation - First Line
RX *sennosides [senna] 8.6 mg 2 tablets by mouth daily as needed
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Incarcerated right femoral hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with an incarcerated right
femoral hernia. You were taken to the operating room and had
your hernia repaired as well as a small hole in your small
intestine. You tolerated the procedure well and are now being
discharged home to continue your recovery with the following
instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10147992-DS-9 | 10,147,992 | 26,054,842 | DS | 9 | 2149-07-17 00:00:00 | 2149-07-17 16:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
naproxen
Attending: ___.
Chief Complaint:
presyncope (lightheadedness)
Major Surgical or Invasive Procedure:
EP study and AVNRT ablation - ___
History of Present Illness:
___ w/PMHx HTN presents for presyncope. Patient developed
lightheadedness while standing in church. No associated chest
pain, SOB, n/v. EMS was called and she was noted to have a heart
rate of 150 with a systolic blood pressure in the ___. Per
report, her SVT broke with venipuncture. She reports she had 3
loose stools afterward. Patient notes occasional episodes of
dizziness, the last of which was 3 weeks ago while she was
driving.
In the ED initial vitals were: 97.8; 92; 131/86; 13; 100% RA
Past Medical History:
Hypertension
Osteoarthritis
Social History:
___
Family History:
+lupus (daughter), HTN. No heart disease, DM.
Physical Exam:
ADMISSON EXAM
=============
VS: 98.0; 148/77; 52; 18; 98 RA
GENERAL: Well developed, well nourished F in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP of 8 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs,
or gallops. No thrills or lifts.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE EXAM
==============
Vitals: T 97.8, BP 121-132/75-83, HR 49-55, RR 16, SpO2 97/RA
I/O: not recorded
Weight: 67.9 kg
Weight on admission: 67.1 kg
Telemetry: sinus rhythm, rates ___
General: well-appearing female, lying flat in bed, NAD.
Lungs: CTAB, no W/R/C
CV: RRR, S1+S2, no M/R/G
Abdomen: non-tender, soft, non-distended
Ext: WWP, no edema. No TTP over b/l groin sites - no hematomas
or bruits.
Pertinent Results:
ADMISSION LABS
==============
___ 10:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-6.5
LEUK-NEG
___ 10:15PM URINE COLOR-Yellow APPEAR-Clear SP ___
IMAGING/STUDIES
===============
___ Cardiovascular EP Brief Procedure Report
rfv and lfv
___
non sustained atrial tachycardia and AVNRT on isoproterenol
slow pathway ablation
no slow pathway post ablation
on and off isoproterenol
___ Cardiovascular ECHO
The left atrium is mildly dilated. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). 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.
The estimated pulmonary artery systolic pressure is normal.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function .
Brief Hospital Course:
___ with past medical history of hypertension who presents for
presyncope, found to have AVNRT.
#CORONARIES: Unknown
#PUMP: Unknown
#RHYTHM: NSR, previously in SVT
#PRESYNCOPE:
#AVNRT: presented with hypotension (SBP in ___ with a narrow
complex tachycardia, consistent with AVNRT. TSH is normal -
unknown precipitant or this later presentation of AVNRT. s/p EP
study and ablation of the slow pathway on ___ after having
inducible AVNRT during EP study. Has remained in sinus rhythm
since with HR in ___. Presyncopal symptoms have resolved.
Ambulating with appropriate response in heart rate. Started on
aspirin 81mg daily after ablation; will need to continue this
for one year (until ___.
#HTN: continued home lisinopril 5mg and amlodipine 5mg
TRANSITIONAL ISSUES
===================
[ ] Started on aspirin 81mg daily, will continue until ___.
[ ] Will follow-up with PCP; can follow-up with EP on an
as-needed basis for any recurrent symptoms or recurrent
arrhythmias.
# CODE STATUS: Full (no prolonged life-sustaining measures)
# CONTACT: ___ (___) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg One tablet(s) by mouth Once a day Disp #*30
Tablet Refills:*0
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
3. amLODIPine 5 mg PO DAILY
4. Lisinopril 5 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
AVNRT
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
WHY WERE YOU ADMITTED TO THE HOSPITAL?
You were found to have a low blood pressure and abnormal heart
rhythm.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You had a procedure in which the source of the abnormal heart
rhythm was identified and burned (called "ablated"), which
should prevent the abnormal rhythm from happening again.
- You were started on aspirin, which you will need to take every
day for one year after your procedure (last day ___.
WHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL?
- Continue to take all of your medicines as prescribed.
- You will see your primary care doctor, ___, in the
office in the next ___ weeks. See below for information on the
appointment.
- If you feel lightheaded, dizziness, palpitations - you should
call your PCP or come to the emergency department to be
evaluated.
Followup Instructions:
___
|
10148145-DS-7 | 10,148,145 | 21,346,827 | DS | 7 | 2162-11-16 00:00:00 | 2162-11-16 13:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Wound dehiscence and infection
Major Surgical or Invasive Procedure:
Placement of irrigating wound vac (___) on ___
Wound irrigation and debridement on ___ with placement of
incisional vac
History of Present Illness:
From Admission HPI:
Mr. ___ is a ___ yo M well known to the neurosurgery team who
is s/p urgent L1-L3 laminectomies, and L2-3 diskectomy on ___
for cauda equina syndrome. He was discharged to ___
but presented on ___ with ongoing wound dehiscence and poor
healing. He was admitted for placement of a wound vac system and
initiation of IV antbiotics. He reports no fevers, chills or
sweats. He notes some improvements in ___ strength with ongoing
___.
Past Medical History:
Morbid obesity
Asthma
Psioriasis
Congenital spinal stenosis
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM:
O: T:98.5 HR: 89 BP:127/77 RR:18 Sat:100% RA
Gen: WD/WN, comfortable, NAD.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
IP Q H AT ___ G
R 5 5 5 0 ___ 0
L 5 5 5 0 0 0
Sensation: decreased in the groin and buttock in the saddle
distribution
Incision:
Malodorous. No active drainage.
___ inch section of dehiscence with depth to the fascia, wound
edges are mildly erythematous. Visualized area of old hematoma
within the cavity.
Incision above and below the open area is well approximated
without erythema or edema.
On Discharge:
Vitals: ___
Gen: WD/WN, comfortable, NAD.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
IP Q H AT ___ G
R 5 5 5 0 ___ 0
L 5 5 5 0 0 0
Sensation: decreased in the groin and buttock in the saddle
distribution
Incision: with serosanguinous drainage (serous > sanguinous).
replaced with new incision vac sponge.
Pertinent Results:
==============================================================
IMAGING
==============================================================
CT Lumbar Spine ___:
IMPRESSION:
1. Compared to ___, there has been interval
evacuation of the
previously seen large posterior subcutaneous hematoma. There is
subcutaneous gas in the region of the hematoma. Recommend
correlation with recent evacuation.
2. There is indistinctness of the posterior spinal musculature,
which could represent a persistent, though decreased, hematoma.
3. Linear lucency through the right L2 inferior facet may
represent a minimally displaced pars defect or artifact
Brief Hospital Course:
___ was admitted to the ___ on ___ from
___ for concern of wound dehiscence and infection
from his prior urgent L1-L3
laminectomies, L2-3 diskectomy on ___ for cauda equina
syndrome.
On ___, he was started on IV cefazolin and received placement
of a ___ irrigating wound vacuum which he tolerated well. He
did not complain of any subjective fevers, chills, or sweats and
his WBC was within normal limits. He remained stable overnight.
On ___, he reported tolerating the wound vac well. He was eager
to return to rehab but per Dr. ___ was asked to remain
in house on antibiotics and with a vac change scheduled for ___
where he could also be examined by Dr. ___.
On ___, he continued to tolerate the wound vac and was
neurologically stable. He remained afebrile without any WBC.
On ___, the wound vac was changed and the patient
continued to do well.
On ___, in the early morning the team was notified that
WoundVac dressing was leaking. Upon inspection, the foam was
found to be intact, and the dressing wasreinforced.
On ___, the patient's neurological and motor exam remained
stable. The team changed the wound-vac dressing with Dr.
___ changed ___ irrigation fluid from saline
to Dakins ___.
On ___, the patient continued to do well and was without fever
or complaint. The WoundVac dressing maintained a good seal.
On ___ the patient remained neurologically stable. His
wound vac remained in place and he was preparing for surgery on
___.
On ___ the patient was taken to the operating room and
underwent a Lumbar Wound Revision. His case was uncomplicated
and he was extubated in the OR and recovered in the PACU. He was
transferred to the floor when stable. He was placed on
vancomycin, cefepime, and flagyl for antibiotic coverage pending
an ID consult.
On ___, the patient continued to be stable on the floor with a
stable neurological exam. He was seen by ID who recommended
vancomycin, ceftazidime, and flagyl while awaiting culture
speciation.
The patient continued to remain stable in house from on ___ and
___ where he continued on vancomycin, ceftazidime, and flagyl.
He did have a run of ventricular tachycardia on ___, lytes and
a formal EKG were obtained that were unremarkable.
The patient was discharged in stable condition on ___. He
was discharged on Vancomycin 1500 mg q8h and ertapenem 1g q24h
both until ___. The patient's incisional vac was changed on
the day of discharge. This vac will be changed by the Prevena
___ Wound Nurse ___ cell: ___ on ___.
Per the infectious disease team, there was no need for ID follow
up at this time. However, the infectious disease team at ___
will continue to monitor the final speciation of his wound
cultures and will notify the team at ___ should any
antibiotic changes be necessary.
This plan was discussed with the patient prior to discharge and
the patient expressed understanding. He will call to schedule a
two week follow up with Dr. ___.
Medications on Admission:
Colace 100 mg capsule
Constulose 10 gram/15 mL oral solution
Dakin's Solution 0.25 %damp gauze with Dakins and cover with
DSD
BID and PRN
Roxicodone 5 mg tablet three times
Sarna Anti-Itch 0.5 %-0.5 % lotion
acetaminophen 650mg every four hrs PRN pain
bisacodyl 5 mg tablet BID PRN
cephalexin 500 mg capsule four times a day
cyanocobalamin (vit B-12) 1,000 mcg tablet once a day
famotidine 20 mg twice a day
gabapentin 900mg TID,
sodium chloride 1 gram TID
zolpidem 5 mg at bedtime
iron -- Unknown Strength
Discharge Medications:
1. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose
Patient should take 1g every 24 hours (course complete on
___.
2. Vancomycin 1500 mg IV Q 8H
3. Bisacodyl 10 mg PO BID:PRN constipation
4. Cyanocobalamin 1000 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Famotidine 20 mg PO BID
7. Ferrous Sulfate 325 mg PO DAILY
8. Gabapentin 600 mg PO TID
9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Mild
10. Sarna Lotion 1 Appl TP QID
11. Zolpidem Tartrate 5 mg PO QHS:PRN sleep
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Wound dehiscence
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid ___
or cane).
Discharge Instructions:
You were admitted to the ___ on ___ for a wound
dehiscence. You received IV antibiotics and placement of an
irrigating wound vacuum and were seen by Dr. ___
recommended antibiotic and wound vac therapy initially.
However, given the depth of your wound, you were taken to the
operating room on ___ for irrigation and debridement of your
wound and placement of an incisional vac. Postoperatively you
were restarted on antibiotics and an infectious disease consult
was placed. They recommended an antibiotic course scheduled to
end on ___. The incisional vac was changed on the day of
discharge and replaced with a new vac sponge. This will be
changed again by the KCI representative on ___ and based on
the appearance of the wound at that time will likely stay in
place until ___.
Followup Instructions:
___
|
10148533-DS-5 | 10,148,533 | 26,200,962 | DS | 5 | 2113-03-03 00:00:00 | 2113-03-03 18:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chief Complaint: fall, seizure
Reason for MICU transfer: s/p seizure requiring intubation for
airway protection, ? GI bleed
Major Surgical or Invasive Procedure:
___ Upper endoscopy
History of Present Illness:
History obtained from ___.
___ ___ speaker with PMH ETOH abuse, s/p fall earlier today
as he was making deliveries for work with +LOC per bystanders.
Patient sustained head strike with abrasion to nose and lip from
this slip on ice. Per report from ED, patient reportedly fell
from 2 feet in driveway +LOC per bystanders, BIBEMS. Per
___, patient had been complaining of hematemesis (unknown
quantity) for past 3 weeks - she is unable to quantify except
that it fills bottom of wash basin. She states he has also had
c/o of increased headache, pressure sensation in the back of his
head for which he chronically takes fioricet. Pt's fiance, ___,
states that he has been a heavy drinker at least for the last ___
years since immigrating from ___. For the last 2 months,
she notes that he has been increasing etoh intake further and
added beer to his regular Bacardi. ___ notes that midnight
prior to presentation, patient was intoxicated and the couple
got into a heated argument. Patient left scene and slept in his
uncle's car outside for the remainder of the night.
Patient has had seizures in the past, first seizure
approximately ___ years ago (at which time he had 3 seizures in ___
year). He had another seizure in ___. This year, he has
had 2 seizures, one in late ___ and a second in late
___ at which time he went to ___
___. He had another one in late ___, early ___.
Both were thought to be secondary to increased etoh use though
unclear - patient was found seizing by witnesses and brought to
ED. ___ states he was discharged with fioricet both times
and has been unable to ___ with PCP for ___ of seizures because
of lack of insurance. He had c/o of increased posterior head
pressure prior to these seizures though he has this chronically.
He has had multiple falls recently including once 8 days ago in
the shower at which time he sustained an abrain on his right
buttock. Since then, he has been complaining of pain on the
right side of his back, requiring increasing doses of motrin.
___ also notes that for last 2 months in the setting of
increased etoh intake, patient has had decreased memory recall
and appears to be regressing emotionally- she notes him playing
with toy trains, etc.
Per ___, review of systems also positive for diaphoresis the
last 3 weeks and c/o of "needing air" for which patient would
sit in front of the fan, though this would not fully alleviate
symptoms. He has also been eating less in the setting of
increased etoh intake. Otherwise, he had not complained of
fevers, chills, chest pain.
In the ED, his initial vitals were: 97.4 90 136/91 16 98%.
On arrival was AOx3. Shortly after arrival to ED, he had
witnessed tonic-clonic seizure x ___ minutes that resolved with
ativan 2mg. Bloody vomitus was noted in his mouth after seizure
(? tongue biting). He was agitated, not following commands (in
___ the seizure and was intubated (8.0 ETT placed with
bougie, no significant aspirate noted in airway) for airway
protection and to perform further evaluation. On propofol ___
mcg/kg/min IV DRIP for sedation. Loaded with keppra 1000mg IV
and dilantin 1000mg IV. Given 2mg ativan. CT head/cspine showed
tiny scalp hematoma over right forehead, no evidence of acute
intracranial abnormality, no C spine fracture. Neurology was
consulted.
Regarding his hematemesis, an OG tube was placed (non-bloody to
suction)- appeared to be undigested gastric content and he was
started on pantoprazole 40 mg IV.
Labs were significant for: lactate 14.5, alt 164, ast 155, nl
alkphos/tbili/lipase, wbc 14.1, hct 47, nl coags, negative urine
and serum tox screens, negative U/A.
ABG showed: ___ s/p intubation with Rate:16;
TV:500; PEEP:5; Mode:Assist/Control
On arrival to the MICU, patient was intubated and sedated.
Past Medical History:
#etoh abuse - since teenager; no history of complex withdrawals,
hospitalizations
#seizures - history of 3 seizures, ___ on
admission; no hx of TBI, anoxic brain injury, family sz hx
#chronic headaches: takes fioricet
Social History:
___
Family History:
No family history of seizure disorder. Almost everyone in his
family has diabetes.
Physical Exam:
FICU ADMISSION EXAM
-------------------
Vitals: T: 98 BP:101/57 P:85 R:14 O2: 99%
Vent settings: CMV, RR14 TV450 Peep 5 FiO240
Sedation: 80 propofol
weight 46.4kg
General- sedated
HEENT- Sclera anicteric, OG tube, ETT in place, dried blood
noted on nares and mouth, pinpoint pupils --> 2 hours later, R
pupil noted to be 1mm larger than left
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- foley in place
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- sedated, +gag reflex, +withdrawal to painful stimuli of
LLE(nailbed pressure)
DAY OF DISCHARGE EXAM
Vitals: T 98.2, BP 128/91, HR 76, RR 18, sat 100% on RA, 600cc
UOP so far today
Gen: young man seated in bed, asleep, awakens easily, then
alert, cooperative, NAD
HEENT: anicteric, pupils symmetric and equally reactive to
light, moist mucous membranes
Chest: equal chest rise, CTAB posteriorly, no cough or work of
breathing
Heart: RRR, no m/r/g, no peripheral edema
Abd: NABS, soft, slightly distended, non-tender, no HSM
Extr: WWP
Skin: some healing abrasions on the soles of his feet and
elsewhere, with scabs, no other significant lesions on limited
exams
Neuro: speaking easily, moving all 4 extr easily, no tremor, CN
intact, strength ___ bilat, sensation intact to light touch
Psych: normal affect
Pertinent Results:
ADMISSION LABS
--------------
___ 05:45PM BLOOD WBC-14.1* RBC-4.68 Hgb-14.6 Hct-47.0
MCV-100* MCH-31.1 MCHC-31.0 RDW-12.1 Plt ___
___ 05:45PM BLOOD ___ PTT-31.0 ___
___ 05:45PM BLOOD Glucose-116* UreaN-11 Creat-0.8 Na-141
K-3.5 Cl-94* HCO3-12* AnGap-39*
___ 05:45PM BLOOD ALT-164* AST-155* AlkPhos-86 TotBili-0.6
___ 05:45PM BLOOD Lipase-17
___ 05:45PM BLOOD CK-MB-4 cTropnT-<0.01
___:01AM BLOOD cTropnT-<0.01
___ 05:45PM BLOOD Albumin-5.7* Calcium-10.4* Phos-3.8
Mg-1.9
___ 08:02PM BLOOD Type-ART Rates-/16 Tidal V-500 PEEP-5
pO2-520* pCO2-32* pH-7.48* calTCO2-25 Base XS-1 -ASSIST/CON
Intubat-INTUBATED
___ 05:49PM BLOOD Glucose-112* Lactate-14.5* Na-143 K-3.3
Cl-101 calHCO3-16*
___ 05:45PM URINE RBC-8* WBC-11* Bacteri-FEW Yeast-NONE
Epi-<1
___ 05:45PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:45PM URINE Color-Yellow Appear-Clear Sp ___
MICRO
-----
___ URINE CX:
___ BLOOD CX X2:
IMAGING
-------
___ CT HEAD: IMPRESSION:
1. No evidence of acute intracranial process.
2. Tiny right scalp, forehead hematoma.
___ CT C spine: IMPRESSION: No cervical spine fracture or
malalignment.
___ CXR: The ET tube tip is at the carina and should be
pulled back. Heart size and mediastinum are grossly stable.
The NG tube tip is in the stomach. Lungs are essentially clear.
No pneumothorax is seen.
___ CT head: (done for anisocoria) IMPRESSION: No acute
intracranial process.
___ US: IMPRESSION:
Mildly echogenic liver consistent with mild hepatic steatosis.
Other forms of liver disease and more advanced liver disease
including significant hepatic fibrosis/cirrhosis cannot be
excluded on this study.
___ EGD: Impression: Normal mucosa in the whole esophagus. No
evidence of varices. Mild erythema in the antrum compatible with
gastritis Mild erythema in the duodenal bulb compatible with
duodenitis Otherwise normal EGD to third part of the duodenum
Recommendations: Plan per inpatient team, recommend ETOH
cessation.
Brief Hospital Course:
___ man with past medical history of alcohol abuse, now
admitted with alcohol withdrawal seizures, mild resolving
alcoholic hepatitis, and a history of hematemesis.
DAY OF DISCHARGE
The patient was feeling ok. He was impatient to leave the
hospital, and said he just wanted to eat and smoke. He denied
any questions about his medical problems or plan of care. I
spoke with his ___ about these things, who translated for
us. We reviewed how disulfiram was not a good idea, how he
would follow-up with Neurology for his headaches and how Fiorcet
was not a good medication for them. We reviewed his elevated
creatinine and the importance of getting follow-up for this.
They had no more questions.
PLAN by PROBLEMS
Alcohol withdrawal seizures, with mild resolving alcoholic
hepatitis, possible alcohol-related memory impairment and falls
- he was treated with the phenobarbital withdrawal protocol and
levetiracetam
- the Neurology consult team saw him during this admission -- it
is possible he has some sort of underlying seizure disorder or
traumatic brain injury, but nothing was found on imaging -- he
will follow-up with them as an outpatient as noted elsewhere
- his viral hepatitis serologies were only notable for Hep A IgG
positivity (IgM was negative)
- the patient's ___ requested consideration of disulfiram --
however, his hepatitis, possible mild nephritis and history of
seizures are relative contraindications
- thiamine, folate, multivitamin to improve nutritional status
History of hematemesis
- he had no bleeding or emesis in the hospital
- an upper endoscopy was done ___ showing gastritis and
duodenitis
- alcohol cessation and low dose omeprazole
- the day of discharge, his Hct was 43.6 (normal)
Acute kidney injury with mild acidosis
- on admission his creatinine was 0.8, it rose to 1.5, and then
fell to 1.3 on the day of discharge -- his BUN remained normal,
and he had good urine output
- a urinalysis showed 8 RBCs, 11 WBCs and 100 of protein
- there was no history to fit with post-renal etiologies, and no
history for acute tubular necrosis -- we suspected either mild
pre-renal azotemia or mild acute interstitial nephritis (perhaps
related to receiving a few doses of a cephalosporin)
- it is important he follows-up with his new primary care doctor
about this in 6 days
Posterior headaches
- CT head x 2 w/o lesions to explain this
- prescribing acetaminophen, naproxen and a small amount of
tramadol for these, follow-up with primary care doctor and
___
Tobacco use and prior drug use
- nicotine patch here, plan to discharge him with one
- SW has seen him and connected him to community resources
Constipation
- prescribed docusate on discharge
ADDITIONAL DETAILS FROM HIS ICU STAY:
Assessment and Plan: ___ with PMH ETOH abuse and prior, recent
episodes of hematemesis s/p unwitnessed fall in driveway and
seizure in ED followed by agitation requiring intubation;
seizures.
# Seizure: Ddx includes alcohol withdrawal vs alcohol-induced
seizures vs underlying seizure disorder with seizure threshold
lowered by heavy EtOH use/withdrawal vs toxin ingestion vs CNS
infection. He was intubated in the ED for airway protection and
extubated after 24 hrs. He was Keppra loaded and started on
phenobarbitol taper for EtOH. CT head showed no evidence of
intracranial pathology, edema, hemorrhage. Quickly after
admission he had no evidence of metabolic abnormality with
normal electrolytes, normal serum osms. U/A did look dirty, but
when patient awoke from sedation after extubation he did not
have urinary complaints. Culture showed no signs of infection.
He had a leukocytosis in the ED, which resolved, suggesting
stress from seizure. Serum tox/Utox negative for etoh or other
drugs. EEG showed no seizure. He had a single fever to 100.7 on
___ after he was awake and neurologic status was improving. He
was briefly on ceftriaxone/vancomycin for meningitis and
acyclovir for HSV encephalitis. However, these were stopped
after <24 hrs because he was clinically well appearing and fever
did not recur.
- Neurology to continue to follow
- phenobarb for EtOH withdrawal
- continue Keppra 1500mg BID
- thiamine, folate, multivitamin
# Asymmetric pupils (R>L): Appears to have occured during course
of hospital stay in ___. Initially there was concern for ICH w/
herniation given that he was sedated, but repeat head CT was
without evidence of hernation or hemorrhage. This resolved when
he was on the floor after being in the ICU.
# Hematemesis: History of 3 weeks of hematemesis prior to
admission. Not a previous problem. Likely ___ UGIB - DDX
includes ___ tear, gastritits, duodenitis, PUD, less
likely variceal given no findings of cirrhosis on exam, normal
h/h, and no prior history of hospitalization for cirrhotic
complications. GI was consulted in the ED and recommended
non-urgent EGD, likely prior to discharge (see above). He did
not require transfusion. He was treated with a PPI.
# Acute kidney injury: Cr 0.8 on admission, which trended up to
1.5 on HD#2. Urine electrolytes were sent to evaluate etiology.
One possibility is pre-renal ___ given that he was NPO ~48 hrs
after admission because of ventilation and obtundation. There
was no reported episode of hypotension in the ER to account for
ischemic ATN. See above for more details.
# Leukocytosis with elevated lactate. Likely ___ seizure given
that the WBC elevation was transient. UA was negative and CXR
not very concerning for PNA.
# Pyuria: with few bacteria, neg nitrite. Concern for UTI. Urine
culture was negative. He received ~48 hrs of ceftriaxone during
admission and this was eventually stopped.
# Elevated LFTs: DDx EtOH, DILI, viral, ischemic. Patient with
history of heavy etoh abuse. AST/ALT elevated but not in typical
2:1 ratio. The transaminase elevations were not in the range of
ischemic liver injury. Synthetic function was otherwise normal.
US did not showed normal portal flow and no nodularity of liver
to suggest cirrhosis.
# Communication:
___ ___
Mother (___) ___
___ (uncle) ___
___ (uncle) ___
___ (uncle) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen-Caff-Butalbital ___ TAB PO Frequency is Unknown
2. Ibuprofen 400 mg PO Frequency is Unknown
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain, headache
RX *acetaminophen 325 mg 2 tablet(s) by mouth Q6H:PRN Disp #*80
Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth BID:PRN Disp
#*60 Capsule Refills:*0
3. LeVETiracetam Oral Solution 1500 mg PO BID
RX *levetiracetam 500 mg 3 TABS by mouth twice a day Disp #*180
Tablet Refills:*0
4. Naproxen 500 mg PO Q12H:PRN headache
RX *naproxen [Naprosyn] 500 mg 1 tablet(s) by mouth BID:PRN Disp
#*60 Tablet Refills:*0
5. Nicotine Patch 14 mg TD DAILY nicotine withdrawl
RX *nicotine 14 mg/24 hour Remove old patch, apply new patch
DAILY Disp #*30 Each Refills:*0
6. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule,delayed ___ by
mouth DAILY Disp #*30 Capsule Refills:*0
7. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth DAILY Disp #*30
Tablet Refills:*0
8. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet
Refills:*0
9. TraMADOL (Ultram) 50 mg PO Q6H:PRN headache
RX *tramadol 50 mg 1 tablet(s) by mouth Q6H:PRN Disp #*40 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol withdrawal, complicated by seizures
Alcoholic hepatitis
Hematemesis due to gastritis and duodenitis
Mild acute kidney injury, resolving at discharge
Headaches
Tobacco use
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with alcohol withdrawal, complicated by
withdrawal seizures and hepatitis (inflammation of the liver due
to alcohol). You also noted a history of hematemesis (vomiting
blood), which was likely related to alcohol use and an endoscopy
showed gastritis and duodenitis (irritation of the stomach and
___ part of the intestines from alcohol). While here we noted
that your kidney function was slightly impaired and thought it
might be related to a few doses of antibiotics you got.
Regardless, it was getting a bit better at the time of
discharge, and you need to be followed up for this as an
outpatient at your primary care doctor's office. As you know,
we discussed with you and your family how it's very important
that you never drink alcohol again.
Followup Instructions:
___
|
10148710-DS-26 | 10,148,710 | 22,361,808 | DS | 26 | 2140-10-17 00:00:00 | 2140-10-21 16:01:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: ___ M hx of multiple surgeries and SBO presents with one day
of abd pain and distention. He reports pain is intermittent,
comes in waves, is sharp, and nonpositional. He denies any
nausea
or vomiting. He reports tolerating breakfast earlier today. He
has not passed flatus today and reports having nonbloody
diarrhea
earlier today. He presents to the hospital because this pain is
worsening and is similar to previous bouts of SBO.
Past Medical History:
PMH:
# Recurrent SBO
# H/O SVT by ___ ___ (asymptomatic)
# H/O shingles over chest ___ (never involving face)
# Vertigo - onset ___, ppt w/ horizontal and vertical head
movements
# AR and mild MR
# HTN
# Crohn's w/ multiple partial SBO
# Peripheral neuropathy
# Gout
# Diverticulitis
# Esophagitis/hiatal hernia
# Hypercholesterolemia
.
PSH:
# ___ Symptomatic cholelithiasis and history of partial
small bowel obstruction - Open cholecystectomy, exploratory
laparotomy and extensive lysis of adhesions
# S/P mole excision to r/o melanoma (no h/o previous atypical
nevi)
# Appendectomy
# Ileal resection (___)
# Exploratory laparotomy, lysis of adhesions (___)
Social History:
___
Family History:
Father had CAD, DM, and Multiple myeloma
Physical Exam:
PHYSICAL EXAMINATION: upon admission: ___
Temp: 98.4 HR: 64 BP: 161/73 Resp: 20 O(2)Sat: 97
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Extraocular muscles
intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft. Mild diffuse lower abdominal TTP
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
Pertinent Results:
___ 04:47AM BLOOD WBC-8.0 RBC-4.58* Hgb-14.4 Hct-42.7
MCV-93 MCH-31.4 MCHC-33.7 RDW-13.2 Plt ___
___ 04:47AM BLOOD WBC-9.4 RBC-4.52* Hgb-14.1 Hct-42.3
MCV-94 MCH-31.3 MCHC-33.4 RDW-13.3 Plt ___
___ 03:05PM BLOOD WBC-9.8# RBC-5.14# Hgb-16.1# Hct-47.5#
MCV-92 MCH-31.4 MCHC-33.9 RDW-13.3 Plt ___
___ 04:47AM BLOOD Plt ___
___ 04:47AM BLOOD Plt ___
___ 04:47AM BLOOD ___ PTT-30.8 ___
___ 04:47AM BLOOD Glucose-104* UreaN-12 Creat-1.2 Na-138
K-4.2 Cl-103 HCO3-27 AnGap-12
___ 04:47AM BLOOD Glucose-104* UreaN-16 Creat-1.2 Na-137
K-4.2 Cl-105 HCO3-26 AnGap-10
___ 03:05PM BLOOD Glucose-120* UreaN-27* Creat-1.2 Na-140
K-4.3 Cl-106 HCO3-26 AnGap-12
___ 04:47AM BLOOD Calcium-9.2 Phos-3.0 Mg-1.7
___ 04:47AM BLOOD Calcium-8.9 Phos-2.6* Mg-1.7
___: x-ray of the abdomen:
IMPRESSION: Findings concerning for early or partial SBO.
___: cat scan of abdomen and pelvis:
. Equivocal findings suggestive of mild acute diverticulitis in
the proximal sigmoid colon. Dindings conveyed to Dr. ___
at approximately 9:15pm on date of exam.
2. Liquid stool throughout the colon could be related to
diarrhea.
3. Stable Richter's hernia through an incisional defect in the
right mid
abdominal wall.
Brief Hospital Course:
___ year old gentleman admitted to the acute care service with
abdominal pain. Upon admission, he was made NPO, given
intravenous fluids, and underwent radiographic imaging of the
abdomen. He was reported to have mild acute diverticulitis.
Findings also included a small right midline ventral abdominal
wall hernia just above level of iliac crests with mild fat
stranding. Operative repair of the hernia was addressed. He
was evaluated pre-op by the anesthesiologist who recommended
follow-up with his cardiologist prior to surgical repair of the
hernia. He was placed on intravenous antibiotics and will be
converted to an oral agent prior to discharge.
His vital signs are stable and he is afebrile. He has started
on clear liquids with progression to a regular diet. His white
blood cell count is normalizing and his hematocrit is stable.
He is preparing for discharge home on a 1 week course of
augmentin. He has instructions to follow up with the acute care
service, his primary care provider and his cardiologist.
Medications on Admission:
tamsulosin SR 0.4', cymbalta 60'', vit B-12 250', ASA 81',
allopurinol ___, lisinopril 5', omeprazole 20',
cyclobenzaprine 10', metoprolol 25'', asacol 1200'''',
gabapentin
1200'', Vitamin B-6 100', folic acid 1 ', fluticasone 50 2
spray''
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
6. gabapentin 400 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
7. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours for 7 days: started ___.
Disp:*14 Tablet(s)* Refills:*0*
8. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
9. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO four times a day.
10. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
11. allopurinol ___ mg Tablet Sig: Two (2) Tablet PO once a day.
12. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO at
bedtime: as needed for muscle spasms.
13. Cymbalta 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
14. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
15. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
16. M-Vit Oral
17. multi-vitamin 1 tablet by mouth daily
18. Vitamin B-12 250 mcg Tablet Sig: One (1) Tablet PO once a
day.
19. omega-3 fatty acids 500 mg Capsule Sig: Three (3) Capsule PO
once a day.
20. Vitamin B-6 100 mg Tablet Sig: One (1) Tablet PO once a day.
21. lactobacillus acidophilus Capsule Sig: One (1) Capsule
PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
diverticulitis
small ventral hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hosptial with abdominal pain. You had
imaging studies done which did not show any obstruction, but did
show diverticulitis. You were also found to have an abdominal
wall hernia. You were started on intravenous antibiotics and
bowel rest. You have gradually resumed your diet and you are
preparing for discharge home with the following instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in 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 have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
___
|
10148710-DS-29 | 10,148,710 | 26,517,626 | DS | 29 | 2141-09-27 00:00:00 | 2141-09-30 14:24:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o Crohn's with remote ileal resection (___), c/b multiple
prior SBOs p/w abd distention, midabdominal pain and n/v.
Having loose stools, however last BM was yesterday, passing
flatus at the moment. Feels current symptoms are consistent with
prior SBOs.
CT in ED showed diffuse jejunal dilatation, decompressed
proximal and distal. +gastric dilatation as well.
Past Medical History:
PMH:
# Recurrent SBO
# H/O SVT by ___ ___ (asymptomatic)
# H/O shingles over chest ___ (never involving face)
# Vertigo - onset ___, ppt w/ horizontal and vertical head
movements
# AR and mild MR
# HTN
# Crohn's w/ multiple partial SBO
# Peripheral neuropathy
# Gout
# Diverticulitis
# Esophagitis/hiatal hernia
# Hypercholesterolemia
.
PSH:
# ___ Symptomatic cholelithiasis and history of partial
small bowel obstruction - Open cholecystectomy, exploratory
laparotomy and extensive lysis of adhesions
# S/P mole excision to r/o melanoma (no h/o previous atypical
nevi)
# Appendectomy
# Ileal resection (___)
# Exploratory laparotomy, lysis of adhesions (___)
Social History:
___
Family History:
Father had CAD, DM, and Multiple myeloma
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 98.8 98.5 59 150/61 20 93%RA
GEN Alert, oriented, appears uncomfortable
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft, moderately distended, diffusely ttp, worst in mid
abdomen, +voluntary guarding, no rebound
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
DISCHARGE PHYSICAL EXAM:
VS 98.1 Tm 99.0 159/70 (->190/62) 50(47-75) 16 95% RA
GEN Alert, oriented, NAD
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft, minimally ttp periumbilically, no rebound or guarding
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Pertinent Results:
___ 06:30AM BLOOD WBC-7.6 RBC-3.95* Hgb-13.0* Hct-38.4*
MCV-97 MCH-32.8* MCHC-33.8 RDW-12.8 Plt ___
___ 05:30AM BLOOD WBC-7.3 RBC-3.76* Hgb-12.5* Hct-35.1*
MCV-93 MCH-33.1* MCHC-35.5* RDW-12.8 Plt ___
___ 05:30AM BLOOD Glucose-105* UreaN-7 Creat-1.0 Na-142
K-3.5 Cl-105 HCO3-25 AnGap-16
___ 03:05PM BLOOD ALT-31 AST-39 AlkPhos-67 TotBili-1.0
___ 06:30AM BLOOD CRP-13.7*
CT abdomen/pelvis ___:
IMPRESSION:
1. Diffuse dilation, up to 4 cm of the mid jejunum through
ileum. There is
air and fluid throughout the bowel without evidence of
transition point.
Findings could represent a jejunitis/ileitis. There is no
evidence of high
obstruction at this time although continued clinical followup
suggested.
2. Stable 1.3 cm soft tissue density next to the left
diaphragmatic crura.
3. Diverticulosis without evidence of diverticulitis
Brief Hospital Course:
___ h/o Crohn's with remote ileal resection (___), c/b multiple
prior SBOs p/w abd distention, midabdominal pain and n/v. Having
loose stools, however last BM was yesterday, passing flatus at
the moment. Feels current symptoms are consistent with prior
SBOs. That patient was admitted for further management of likely
pSBO.
#abdominal pain/n/v: given the patient's history, exam findings
and CT scan, the most likely diagnosis for the patient's
presenting symptoms was a partial small bowel obstruction. He
was made NPO, started on maintainence IVFs and his pain was well
controlled with IV morphine. He declined an NG tube. Stool
cultures were negative. Given that the CT findings were not
entirely consistent with a pSBO, GI was initially consulted to
evaluate whether the diffuse jejunal dilatation on CT could be
consistent with a Crohn's flare. CRP was 13 and the history was
highly suggestive of pSBO, thus they felt a Crohn's flare was
unlikely. Acute care surgery was also consulted given that Mr.
___ is a patient of Dr. ___ well known to the
service. They agreed that pSBO was also the most likely
diagnosis.
The patient was having BMs and passing flatus by HD1 and his
abdominal distention improved. He had no episodes of nausea or
vomiting while in-house. His mid abdominal pain steadily
improved and by HD4 began tolerating a clear liquid diet. He was
advanced to a regular diet on the day prior to discharge. On
the day of discharge, his distention had resolved and his
abdominal pain/tenderness was minimal. He was instructed to
follow up with Dr. ___ as schedule in the coming weeks.
INACTIVE ISSUES:
# Hypertension: the patient's HR was consistently in the low
___ (asymptomatic) initially, thus his metoprolol was
cut in half. His BPs were elevated to 150s-160s. His lisinopril
was increased from 5mg to 7.5mg daily.
#HLD: continued atorvastatin
#h/o diverticulitis: no evidence of diverticulitis on admission
CT abdomen/pelvis.
#Crohn's disease s/p ileal resection: no evidence of flare on
admission, CRP was 13 as above.
# Gout: continue home allopurinol, with dose adjustment for
renal function if needed
# Neuropathy: Symptoms are currently well-controlled, without
pain
-continue gabapentin and duloxetine
Transitional Issues:
1. HTN: his BP was not well controlled in-house. We increased
his home lisinopril to 7.5mg daily. Given his bradycardia, we
decreased his home dose to Toprol 25mg from 50mg. His BPs were
still elevated ~150s upon discharge (asymptomatic), he may
require additional anti-hypertensives to be initiated as an
outpatient. He will also need a follow-up chem-7 to check his
potassium after the lisinopril increase.
2. h/o diverticulitis: the patient will follow up as scheduled
in the coming weeks with Dr. ___ to discuss whether he will
go ahead as planned to have a sigmoid colectomy for recurrent
diverticulitis in the setting of this recent pSBO.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
hold if SBP<90
2. Mesalamine 1200 mg PO QID
3. mometasone *NF* 0.1 % Topical BID
4. MetronidAZOLE Topical 1 % Gel 1 Appl TP Frequency is Unknown
uses the 0.75% concentration
5. Gabapentin 1200 mg PO BID
6. lactobacillus acidophilus *NF* 1 capsule Oral qdaily
7. Allopurinol ___ mg PO DAILY
8. Fish Oil (Omega 3) 1500 mg PO DAILY
9. Metoprolol Tartrate 50 mg PO DAILY
hold if SBP<90, HR<55
10. Cyclobenzaprine 10 mg PO DAILY:PRN muscle spasm
11. Fluticasone Propionate NASAL 2 SPRY NU DAILY
12. Atorvastatin 10 mg PO DAILY
13. Multivitamins W/minerals 1 TAB PO DAILY
14. Omeprazole 20 mg PO DAILY
15. Aspirin 81 mg PO DAILY
16. Duloxetine 60 mg PO BID
17. Tamsulosin 0.4 mg PO HS
18. Cyanocobalamin 250 mcg PO DAILY
19. FoLIC Acid 1 mg PO DAILY
20. Pyridoxine 100 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Cyanocobalamin 250 mcg PO DAILY
5. Cyclobenzaprine 10 mg PO DAILY:PRN muscle spasm
6. Duloxetine 60 mg PO BID
7. Fish Oil (Omega 3) 1500 mg PO DAILY
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Gabapentin 1200 mg PO BID
11. Lisinopril 7.5 mg PO DAILY
hold if SBP<90
12. Mesalamine 1200 mg PO QID
13. Metoprolol Tartrate 25 mg PO DAILY
hold if SBP<90, HR<55
14. Omeprazole 20 mg PO DAILY
15. Pyridoxine 100 mg PO DAILY
16. Tamsulosin 0.4 mg PO HS
17. lactobacillus acidophilus *NF* 1 capsule Oral qdaily
18. MetronidAZOLE Topical 1 % Gel 1 Appl TP BID
uses the 0.75% concentration
19. mometasone *NF* 0.1 % Topical BID
20. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Partial small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your admission to
___ for abdominal pain. We believe this pain may have been
caused by a partial bowel obstruction. We initially kept you
NPO and your pain slowly improved. You were seen by Dr.
___ the surgery team and you will follow up with them
as an outpatient.
Your diet was advanced, which you tolerated well.
Your blood pressure was too high in the hospital. We increased
your home lisinopril from 5mg to 7.5mg. You need to buy a blood
pressure cuff for home and keep a daily log of your blood
pressures.
You also should have it arranged to have your potassium checked
at your appointment with Dr. ___ on ___ given that we
increased your lisinopril here in the hospital (this medication
can increase your potassium level).
Followup Instructions:
___
|
10148710-DS-30 | 10,148,710 | 20,807,610 | DS | 30 | 2143-12-12 00:00:00 | 2143-12-12 15:12:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male with well controlled Crohn's s/p remote
ileocecectomy,
recurrent SBOs, multiple abd surgeries by ___ presents
to
ED with 3 days of mid abdominal pain, nausea and imaging
concerning for small bowel obstruction. Patient reports he has
had of multiple SBOs with hx of exlap/LOA in 06' and ___' and
last
episode in ___ managed conservatively. He has been doing well
though with baseline chronic abdominal pain followed by
___ with a negative workup including MRE ___ recurrence of crohns. He reports
his
last crohn's flare was prior to his ileocecectomy in ___ and
it has been very well controlled on his oral regimen. Patient
reports gradual onset of midabdominal pain 3 days ago with acute
worsening in last 24hrs and nausea but no emesis. Pain is crampy
and does not radiate. Upon presentation to the ED, he had normal
vitals, normal labs other than elevated Cre which is at his
baseline, CT abd/pelvis w/PO contrast which showed dilated loops
of small bowel with a transition point in the mid abdomen.
Patient has since had 2 loose BMs in the ED with flatus. He
continues to have crampy abdominal pain without any nausea.
Denies any fevers, chills, bloody stools or dysuria.
Past Medical History:
PMH:
# Recurrent SBO
# H/O SVT by ___ ___ (asymptomatic)
# H/O shingles over chest ___ (never involving face)
# Vertigo - onset ___, ppt w/ horizontal and vertical head
movements
# AR and mild MR
# HTN
# Crohn's w/ multiple partial SBO
# Peripheral neuropathy
# Gout
# Diverticulitis
# Esophagitis/hiatal hernia
# Hypercholesterolemia
.
PSH:
# ___ Symptomatic cholelithiasis and history of partial
small bowel obstruction - Open cholecystectomy, exploratory
laparotomy and extensive lysis of adhesions
# S/P mole excision to r/o melanoma (no h/o previous atypical
nevi)
# Appendectomy
# Ileal resection (___)
# Exploratory laparotomy, lysis of adhesions (___)
Social History:
___
Family History:
Father had CAD, DM, and Multiple myeloma
Physical Exam:
PE: upon admission: ___
97.9 73 116/79 18 96%RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, mildly distended, tympanic to percussion, tender to
light palpation in LUQ and LLQ, no rebound tenderness, no
guarding
Ext: No ___ edema, ___ warm and well perfused
Physical examination upon discharge: ___:
General: NAD
vital signs: 99.1, hr=60, bp=158/60, rr=16, 97% room air
CV: Ns1, s2, -s3 -s4, + Grade ___, systolic murmur, ___ ICS,
RSB, LSB
LUNGS: clear
ABDOMEN: soft, non-tender, hypoactive BS, no hepatomegaly, no
splenomegaly
EXT: no pedal edema bil., no calf tenderness bil
NEURO: alert and oriented x 3, speech clear
Pertinent Results:
___ 04:10AM BLOOD WBC-7.9 RBC-3.79* Hgb-12.6* Hct-34.8*
MCV-92 MCH-33.3* MCHC-36.2* RDW-13.0 Plt ___
___ 07:00PM BLOOD WBC-6.7 RBC-3.88* Hgb-12.8* Hct-36.7*
MCV-95 MCH-33.0* MCHC-34.9 RDW-13.2 Plt ___
___ 12:25AM BLOOD WBC-9.7# RBC-4.63 Hgb-15.1 Hct-43.4
MCV-94 MCH-32.6* MCHC-34.8 RDW-13.3 Plt ___
___ 07:00PM BLOOD Neuts-68.9 ___ Monos-6.9 Eos-2.6
Baso-0.2
___ 04:10AM BLOOD Plt ___
___ 04:10AM BLOOD Glucose-150* UreaN-15 Creat-1.1 Na-139
K-3.7 Cl-103 HCO3-25 AnGap-15
___ 04:10AM BLOOD Calcium-9.3 Phos-3.0 Mg-1.7
___ 12:41AM BLOOD Lactate-1.2
___: x-ray of the abdomen:
Nonspecific bowel gas pattern, compatible with ileus or early
obstruction. If clinical concern remains for small bowel
obstruction, a CT is recommended.
___: cat scan of abdomen and pelvis:
1. Findings compatible with small bowel obstruction, with
transition point in the low anterior mid abdomen, as described
above. Etiology may be due to a stricture or adhesion.
Fecalalized small bowel content proximal to zone of transition
suggests a subacute or chronic obstruction, and preserved gas
and fluid in the colon may reflect early or incomplete
obstruction.
2. No evidence of abdominal abscess or free fluid.
3. Hepatic steatosis.
___: x-ray of the abdomen:
frontal supine and 2 frontal erect views of the upper and lower
abdomen are submitted. Dilute contrast agent is present in
normal caliber large bowel. The supine views best show distended
small bowel loops clustered in the mid abdomen, 33-58 mm in
diameter. Since the stomach and small bowel proximal to these
loops are not distended, these may be dilated due to local
inflammation.
There is no evidence of intestinal perforation Careful followup
is advised.
Brief Hospital Course:
The patient was admitted to the hospital with crampy abdominal
pain. Upon admission, the patient was made NPO, given
intravenous fluids, and underwent imaging of the abdomen which
showed dilated loops of small bowel with a transition point in
the mid abdomen, findings concerning for a small bowel
obstruction. The patient was placed on bowel rest. Shortly
after admission, he had return of bowel function. He was placed
on clear liquid diet and he had no further recurrence of
abdominal pain. On HD # 3, the patient progressed to a regular
diet. His vital signs remained stable and he was afebrile. He
was ambulating without difficuly. The patient was discharged
home on HD #3 in stable condition. He was instructed to
follow-up with his primary care provider and GI physician.
Medications on Admission:
Lisinopril 5' Mesalamine 1200'''', Gabapentin 1200'',
lactobacillus acidophilus', Allopurinol ___, Fish Oil 1500',
Metoprolol 50', Cyclobenzaprine 10prn, Fluticasone NASAL 2
spray'', Atorvastatin 10', MTV, Omeprazole 20', Aspirin 81',
Duloxetine 60'', Tamsulosin 0.4qhs, Cyanocobalamin 250', FoLIC
Acid 1', Pyridoxine 100'
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Duloxetine 60 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Gabapentin 1200 mg PO BID
7. Lisinopril 5 mg PO DAILY
8. Mesalamine ___ 2400 mg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with abdominal pain. You
underwent a cat scan of the abdomen which showed a small bowel
obstruction. You were placed on bowel rest. After return of
bowel function, you were started on a diet. Your bowel function
has returned and you are now preparing for d/c home with the
following instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in 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 have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Followup Instructions:
___
|
10148993-DS-2 | 10,148,993 | 28,081,253 | DS | 2 | 2140-06-05 00:00:00 | 2140-06-05 13:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Augmentin
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male ___ instructor with
history of migraines, borderline hypertension, and migraines who
was punched in the head by one of his martial ___ students
approximately 9 days ago. He denies LOC. He was admitted to ___ for 3 days and had serial head CTs. Imaging not
available for review however per ED report there is new midline
shift compared to ___ CT reports. He was discharged on 5 days of
Keppra which he completed and has a neurology follow-up
appointment on ___ with ___. He denies taking
anticoagulants. He is currently taking Tramadol and Tylenol for
his headaches. He was taking Fioricet for his migraines prior to
this head injury. He presents to ___ ED for "second opinion"
due to ongoing headaches, intermittent nausea, blurred vision
and
photophobia which he reports is improving. He denies vomiting,
falls, prior head injuries, difficulty walking, tremors,
numbness, tingling and weakness.
Past Medical History:
Borderline HTN
Asthma
Migraines
Social History:
___
Family History:
NC
Physical Exam:
ON ADMISSION:
PHYSICAL EXAM:
O: Lying on stretcher. NAD.
T: 96.0 BP: 157/100 HR: 72 R: 14 O2Sats: 100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3-2mm PERRL. EOMs intact without nystagmus
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2mm
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.
Negative Rhomberg.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch.
Coordination: normal on finger-nose-finger, rapid alternating
movements.
ON DISCHARGE:
Gen: WD/WN, comfortable, NAD.
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2mm
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.
Pertinent Results:
___ CT HEAD W/O CONTRAST
A subacute on chronic subdural hemorrhage 8 mm in maximal
diameter with mild sulcal effacement and 5 mm midline shift. No
priors available for comparison to assess for change.
___ 11:50AM LACTATE-1.6
___ 11:30AM GLUCOSE-77 UREA N-14 CREAT-1.3* SODIUM-143
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-31 ANION GAP-13
___ 11:30AM estGFR-Using this
___ 11:30AM WBC-6.0 RBC-5.39 HGB-15.2 HCT-45.6 MCV-85
MCH-28.2 MCHC-33.3 RDW-13.3 RDWSD-40.9
___ 11:30AM NEUTS-58.8 ___ MONOS-9.5 EOS-1.7
BASOS-0.5 IM ___ AbsNeut-3.52 AbsLymp-1.74 AbsMono-0.57
AbsEos-0.10 AbsBaso-0.03
___ 11:30AM PLT COUNT-340
___ 11:30AM ___ PTT-33.6 ___
Brief Hospital Course:
Mr. ___ presented to the emergency department with complaints
of headache on ___ 10 days after being struck in the head by
a student in his martial arts class. He was initially evaluated
at ___ where he was noted to have a small subdural hematoma
without documented midline shift. Repeat NCHCT on ___
showed midline shift. He received medication in the ED for
headache management and was admitted overnight to neurosurgery.
On ___, the patient remained hemodynamically and neurologically
stable. He was discharged home with plan to follow up in clinic
as an outpatient on ___ with repeat NCHCT.
Medications on Admission:
Lexapro 20mg daily, Seroquel 200mg, wellbutrin 300, Tramadol
50mg, Albuterol inh, Tylenol PRN, Fioricet PRN
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing
3. Docusate Sodium 100 mg PO BID
4. TraMADol 50 mg PO Q4H:PRN headache
RX *tramadol 50 mg 1 tablet(s) by mouth Every 6 hours as needed
Disp #*24 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Subdural hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
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.
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.
Followup Instructions:
___
|
10148993-DS-3 | 10,148,993 | 25,023,703 | DS | 3 | 2143-08-10 00:00:00 | 2143-08-22 14:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Augmentin / Fioricet
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
A ___ presenting with 3 days of acute-onset abdominal pain. The
patient was in USOH until 3 days ago when he developed sharp,
constant LLQ abdominal pain following a meal. He initially
attributed his symptoms to food poisoning. He was briefly
febrile to ___. Since the onset of symptoms, he has had 5+
episodes of non-bloody, non-bilious emesis and several episodes
of non-bloody
diarrhea. He has felt nauseous but has been able to tolerate
fluids. He denies pneumaturia or other urinary changes. He had a
colonoscopy approximately ___ years ago which identified several
polyps. He denies any history of diverticulitis or experiencing
similar pain previously. He denies recent illnesses.
Past Medical History:
Borderline HTN
Asthma
Migraines
Social History:
___
Family History:
Non-contributory
Physical Exam:
Physical Exam on Admission:
VS: T 98.6 HR 89 BP 148/83 RR 18 98% RA
GEN: A&O, NAD
CV: RRR
PULM: Unlabored breathing
ABD: Soft, non-distended, tender to palpation in LLQ, tender in
LLQ with palpation of RLQ
Physical Exam on Discharge ___:
VS: T 98.4 BP 144/91 HR 75 RR 18 O2 sat: 95% RA
GEN: NAD. A+Ox3.
CV: RRR
Pulm: Lung sounds clear bilaterally
Abd: Soft, non-distended. Tender to palpation on LLQ.
Ext: No edema or pain.
Pertinent Results:
___ 05:38AM BLOOD WBC-8.1 RBC-4.79 Hgb-13.4* Hct-40.2
MCV-84 MCH-28.0 MCHC-33.3 RDW-13.4 RDWSD-41.6 Plt ___
___ 11:32AM BLOOD Neuts-82.1* Lymphs-8.7* Monos-8.5
Eos-0.0* Baso-0.1 Im ___ AbsNeut-11.98* AbsLymp-1.27
AbsMono-1.24* AbsEos-0.00* AbsBaso-0.02
___ 05:38AM BLOOD Glucose-113* UreaN-12 Creat-1.3* Na-143
K-4.0 Cl-104 HCO3-25 AnGap-14
___ 05:38AM BLOOD ALT-16 AST-15 AlkPhos-70 TotBili-1.0
___ 05:48AM BLOOD TotBili-2.0* DirBili-0.6* IndBili-1.4
___ 05:38AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.9
___ 11:49AM BLOOD Lactate-1.5
CTU (ABD/PEL) W/CONTRAST ___:
Acute sigmoid diverticulitis with trace associated free air
suggesting micro perforation. No drainable collection.
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Brief Hospital Course:
Mr. ___ presented to the Emergency Department on ___ for
LLQ abdominal pain. He was evaluated by the acute care surgery
service upon arrival to the ED. CT imaging that was done showed
acute sigmoid diverticulitis. Given findings, the patient was
transferred to the floor for bowel rest under the ACS service.
He was made NPO, given IVF, started on IV antibiotics, ordered
for pain medication and serial abdominal exams. On HD1, his diet
was advanced to a regular diet, which the patient tolerated. He
was subsequently put on his home medications and his IV
antibiotics were switched to PO Cipro and Flagyl (10-day
course). His laboratory values were monitored and his total
bilirubin was noted to be elevated at 2.0. An MRCP was ordered
to be done inpatient, but it was decided because the patient was
doing well clinically that he could go home and get an MRCP as
an outpatient.
At the time of discharge, the patient was doing well, afebrile,
and hemodynamically stable. He was tolerating a regular diet,
ambulating, voiding, and pain was well controlled. The patient
received discharge teaching including about antibiotic
medication and side effects as well as follow-up instructions
with understanding verbalized and agreement with the discharge
plan. He will only need follow up with his primary care
physician (plan for a colonoscopy in 6 weeks), with an
appointment already scheduled for him prior to discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
3. BuPROPion XL (Once Daily) 300 mg PO DAILY
4. Citalopram 20 mg PO DAILY
5. Flovent HFA (fluticasone propionate) 220 mcg/actuation
inhalation BID
6. Gabapentin 300 mg PO QHS
7. Prazosin 4 mg PO QHS
8. QUEtiapine Fumarate 200 mg PO QHS
9. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
10. ginseng 100 mg oral DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
Please do not exceed 4gm in a 24 hour period.
2. Ciprofloxacin HCl 500 mg PO BID Duration: 10 Days
Finish on ___.
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*16 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO Q8H Duration: 10 Days
Finish on ___.
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*24 Tablet Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
Please take the lowest effective dose and wean as tolerated.
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*6 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY
Hold for loose stool.
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
8. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
9. BuPROPion XL (Once Daily) 300 mg PO DAILY
10. Citalopram 20 mg PO DAILY
11. Flovent HFA (fluticasone propionate) 220 mcg/actuation
inhalation BID
12. Gabapentin 300 mg PO QHS
13. ginseng 100 mg oral DAILY
14. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
15. Prazosin 4 mg PO QHS
16. QUEtiapine Fumarate 200 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ because of abdominal pain. Imaging
done here showed you had acute sigmoid diverticulitis, which is
an inflammation in your large intestines. You were put on bowel
rest, so you were given IV fluids, kept NPO (nothing by mouth),
and started on a course of antibiotics to treat your
diverticulitis. Your abdominal pain has since decreased and you
were slowly advanced to a regular diet, which you are
tolerating. Your pain has been well-controlled on oral pain
medication. While you were here, your blood was drawn and your
total bilirubin level was elevated, so you were ordered for a
MRCP (magnetic resonance cholangiopancreatography), but this can
be done as outpatient once you see your primary care physician.
You are doing well and ready to be discharged home. You will
need to finish your course of antibiotics. Please follow the
instructions below:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
10149067-DS-17 | 10,149,067 | 27,304,639 | DS | 17 | 2183-07-01 00:00:00 | 2183-07-01 21:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
fall, right finger numbness
Major Surgical or Invasive Procedure:
___: C4 corpectomy, C3-4 ACDF
History of Present Illness:
___ yo F hx DM, HTN on ASA 81mg who tripped and fell down the
stairs. She struck her head on the wall and had + LOC. When she
awoke she was wedged against the wall upside down, landing on
her neck. She was able to move and got up to seek help. She
reports numbness and tingling in the first 3 digits of her right
hand and difficulty gripping with her right hand. She also c/o
pain in the mid back and lower left scapula. She denies any
bowl or bladder incontinence.
Past Medical History:
DM type 2, HTN
Social History:
___
Family History:
non-contributory
Physical Exam:
Upon discharge:
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: PERRL
EOM: [x]Full [ ]Restricted
Speech Fluent: [ ]Yes [x]No - improving dysphonia
Comprehension intact [x]Yes [ ]No
Motor:
Deltoid BicepTricepGrip
Right5 5 5 4+
___ 5
IPQuadHamATEHLGast
___
Left 5 5 5 5 5 5
[x]Sensation intact to light touch - slight numbness to 3 toes
on R foot
Neck is soft, trachea is midline. Incision OTA with steri
strips,
cervical collar in place
Pertinent Results:
Please see OMR for pertinent results.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the neurosurgery team. The patient was found to
have significant cervical spine stenosis as well as a C3-4 disc
protrusion and was admitted to the neurosurgery service.
#Chest Tightness
She was preoperatively prepared and expectantly monitored until
it was time for her to undergo surgery. She did experience
multiple instances of subjective chest tightness preoperatively.
These were worked up by EKG and troponins, which were negative.
These episodes self resolved each time.
#cervical spine stenosis, C3-4 disc protrusion
The patient was taken to the operating room on ___ for C4
corpectomy, C3-C4 ACDF, 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 per routine. The
patient's home medications were continued throughout this
hospitalization or adjusted appropriately for inpatient stay.
#Odynophagia
On ___, the patient complained of pain with swallowing. She was
transferred to the step-down unit for closer monitoring. ENT was
consulted, and the patient's airway was scoped and determined to
have edema. She was started on steroids per ENT which were
discontinued on ___. The patient reported improved symptoms
after steroid treatment. She was re-scoped on ___ by ENT who
reported improved edema.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Omeprazole 20 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
3. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN sore throat
4. Cyclobenzaprine 10 mg PO TID:PRN Pain
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth TID PRN Disp #*21
Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
6. Metoprolol Tartrate 12.5 mg PO Q12H
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
every twelve (12) hours Disp #*30 Tablet Refills:*0
7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4H PRN Disp #*45
Tablet Refills:*0
8. Ramelteon 8 mg PO QHS
Should be given 30 minutes before bedtime
RX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth QHS PRN Disp
#*30 Tablet Refills:*0
9. Senna 8.6 mg PO BID
10. Losartan Potassium 75 mg PO DAILY
RX *losartan 25 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
13. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until ok with neurosurgeon.
Discharge Disposition:
Home
Discharge Diagnosis:
Significant stenosis of the cervical spine, C3-4 disc protrusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Surgery
-Your incision is closed with dissolvable sutures underneath the
skin and steri strips. You do not need suture removal. Do not
remove your steri strips, let them fall off.
-Please keep your incision dry for 72 hours after surgery.
-Please avoid swimming for two weeks.
-Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
-You must wear your hard cervical collar at all times. You may
remove it briefly for skin care and showering and re-apply.
-We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
-You make take leisurely walks and slowly increase your activity
at your own pace. ___ try to do too much all at once.
-No driving while taking any narcotic or sedating medication.
-No contact sports until cleared by your neurosurgeon.
-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.
-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.
Followup Instructions:
___
|
10149316-DS-7 | 10,149,316 | 20,642,594 | DS | 7 | 2201-09-13 00:00:00 | 2201-09-19 14:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Allopurinol / Cefepime
Attending: ___.
Chief Complaint:
ptosis, diplopia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr ___ is a ___ yr old male with longstanding history of
CLL and hypogammaglobulinemia on IVIG, has been treated w/
ibrutinib since ___.
Pt was seen in neurology clinic today and noted to have new
ptosis and diplopia and was referred to ED. He has hx of
trigeminal neuralgia, episode of shingles in ___ over L upper
forehead and eyebrow region. He had persistent numbness of L
lower lip and chin since that time as well as shooting pains
over the L face. He was seen by Dr ___ these symptoms,
started on gabapentin and face pains have improved. He cont to
note numbness over the L chin/lower jaw region. He reports
drooping of his L eye and intermittent double
vision for at least one week. slight ptosis noted in clinic
visit ___ and again during neurology visit today also noted to
have diplopia. Pt notes double vision of my face intermittently
during interview only when both eyes open and esp w/ looking to
R. he is able to read the clock on the wall. Denies any balance
trouble or difficulty walking due to vision. Denies any eye
pain, redness or blurry vision or loss of vision. Denies HA,
new numbness or weakness. He was referred for brain MRI and
further eval.
REVIEW OF SYSTEMS:
GENERAL: No fever, chills, night sweats, recent weight changes.
HEENT: No mouth sores, odynophagia, sinus tenderness,
rhinorrhea, or congestion.
CARDS: No chest pain, chest pressure, exertional symptoms, or
palpitations.
PULM: No cough, shortness of breath, hemoptysis, or wheezing.
GI: No nausea, vomiting, diarrhea, constipation or abdominal
pain. No hematochezia, or melena.
GU: No dysuria, hematuruia or frequency.
MSK: No arthritis, arthralgias, myalgias, or bone pain.
DERM: Denies rashes, itching, or skin breakdown.
NEURO: as above
HEME: No bleeding or clotting
Past Medical History:
1. CLL as above
2. Hypogammaglobulinemia
3. Trigeminal neuralgia, left
4. Seborrheic keratosis
5. Squamous cell cancer
6. Palmar fascia contracture
Social History:
___
Family History:
Of his three siblings, one brother died at ___ with a heart
attack. His two sisters are healthy. His mother died at ___ and
his father died at ___ with prostate cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD alert
VITAL SIGNS: 98 122/78 69 99%RA
HEENT: MMM, no OP lesions,
Neck: supple, no JVD
Lymph: no cervical, supraclavicular, axillary or inguinal
adenopathy
CV: RR, NL S1S2 no S3S4 or MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
EXT: warm well perfused, no edema
SKIN: No rashes or skin breakdown
NEURO: alert and oriented x 4, ___, unable to fully adduct L
eye although it does cross midline. +L ptosis no nystagmus, face
symmetric, no tongue deviation, full hand grip, shoulder shrug
and bicep flexion, full toe dorsiflexion and hip flexion against
resistance bilateral, sensation intact to light touch, no
clonus, visual fields full to confrontation. no dysmetria w/ FTN
or RAM. Gait normal
.
DISCHARGE PHYSICAL EXAM:
Vitals: AF, 98, 124/70, 74, 18, 98% on RA
Gen: NAD, at bedside
Eyes: + left ptosis, can NOT adduct left eye
ENT: MMM, OP clear
Cardiovasc: RRR, no murmur
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, NT, ND, BS+
Skin: No visible rash. No jaundice.
Neuro: AAOx3. fluent speech.
Psych: Full range of affect
Pertinent Results:
ADMISSION LABS:
___ 11:22PM BLOOD WBC-26.8* RBC-2.91* Hgb-8.8* Hct-26.6*
MCV-91 MCH-30.2 MCHC-33.1 RDW-15.5 RDWSD-50.8* Plt ___
___ 11:22PM BLOOD ___ PTT-38.2* ___
___ 11:22PM BLOOD Glucose-102* UreaN-24* Creat-0.8 Na-138
K-3.7 Cl-103 HCO3-21* AnGap-18
___ 11:22PM BLOOD ALT-27 AST-41* LD(LDH)-292* AlkPhos-725*
TotBili-0.3
___ 06:00PM BLOOD TotProt-6.4 Albumin-3.9 Globuln-2.5
Calcium-9.2 Phos-2.8 Mg-2.1
___ 11:22PM BLOOD UricAcd-8.3*
___ 06:00PM BLOOD TSH-2.9
___ 06:00PM BLOOD Free T4-1.2
___ 06:00PM BLOOD PTH-49
___ 06:00PM BLOOD 25VitD-40
___ 11:22PM BLOOD PSA-___*
___ 06:00PM BLOOD PEP-NO SPECIFI IgG-729 IgA-27* IgM-20*
IFE-NO MONOCLO
___ 06:00PM BLOOD tTG-IgA-1
IMAGING:
___ MRI HEAD
IMPRESSION:
1. Acute on chronic infarction of the left basal ganglia.
2. New, diffuse osseous metastases in the clivus, visualized
upper cervical spine, and calvarium.
3. The large ventricles with prominent temporal horns and small
convexity sulci can be due to communicating hydrocephalus in
proper clinical setting.
4. Paranasal sinus disease.
.
.
___ Echocardiogram
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Mildly
dilated ascending aorta and mild aortic regurgitation. Atrial
and ventricular ectopy noted.
.
.
___ MRI C-SPINE
IMPRESSION:
1. Diffuse osseous metastases throughout the cervical spine.
2. Multilevel degenerative changes of the cervical spine, most
advanced at C5-C6, where there is severe spinal canal, severe
right neural foraminal, and moderate left neural foraminal
stenosis.
___ MRI HEAD with CONTRAST
IMPRESSION:
1. Enhancing mass in the left Meckel's cave, encasing the left
cavernous internal carotid artery, most likely representing
metastases.
2. Diffuse osseous metastases in the clivus and calvarium.
3. Unchanged chronic infarction in the left putaminal and
caudate head.
.
___ MRI T/L SPINE
IMPRESSION:
1. Diffusely abnormal bone marrow signal throughout the thoracic
and lumbar spine and the visualized sacrum consistent with
diffuse bony metastatic disease.
2. Mild multilevel spinal canal stenosis and mild-to-moderate
neural foraminal stenosis, as described above.
3. Abnormal dural versus intradural enhancement at the level of
T12-L3, of uncertain etiology and may represent malignant
involvement. Correlation with lumbar puncture can be performed
if clinically indicated.
4. Presacral edema of uncertain etiology with no definite
fracture seen, although pathologic fracture cannot be excluded.
Recommend CT of the sacrum for further evaluation.
5. Partially visualized retroperitoneal lymphadenopathy.
6. Partially visualized patchy left basilar airspace disease.
.
.
___ MRI Pituitary
IMPRESSION:
1. Partially visualized subacute infarction of the left putamen
and caudate head.
2. Re- demonstration of the expansile heterogeneously contrast
enhancing lesion in the left Meckel's cave with associated dural
invasion along the anterior medial left temporal lobe.
3. Additional lesion in the anterior right cavernous sinus
extending into and expanding the right foramen rotundum.
4. Partially visual calvarial metastatic disease.
5. Normal appearance the pituitary gland.
.
.
Brief Hospital Course:
___ man with a longstanding history of CLL now on
imbrutinib since ___. Referred from ___ clinic w/ new
ptosis and diplopia for at least one week.
#Ptosis/Diplopia due to acute on chronic CVA from possible AVM
with bleeding vs clivus lesion: On MRI the patient has a left
basal ganglia acute on chronic CVA from likely an AVM following
discussion with Dr ___. He also has mets to the upper
cervical spine and calvarium that would be from likely new
metastatic prostate CA.
Per discussion with Dr. ___ antiplatelet agents (not on
any). No events on tele and cardiac echocardiogram is
unremarkable. He will follow-up in ___.
# New diagnosis of metastatic prostate cancer: PSA elevated to
___ with bone mets. Per discussion with ___ consult team
patient does not need biopsy as it is classic for metastatic
prostate cancer. He was started on bicalutamide 150 mg oral
DAILY (started ___ and complete MR spine with contrast that
showed multiple lesions in the spine c/w metastatic disease.
There was also some dural enhancement seen on the MRI, and an LP
can be considered by Neuro-Oncology. Will need follow up in
___ clinic with ___, MD (___) with likely
Dr. ___ in ___ ___ clinic.
# CLL - WBC in stable range, ALC 80-90%.
- Continued ibrutinib
# History of hypogammaglobulinemia. Received IVIG in clinic
last week. He is due for his next monthly dose in ___.
# Elevated alkP - Likely related to metastatic prostate CA. pt
underwent U/S of RUQ, liver MRI which was unrevealing. He was
evaluated by GI and underwent liver biopsy ___ which showed
mononuclear infiltrate, concerning for lymphoma as well as
inflammatory features present suggestive of a mild concomitant
hepatitis, most likely secondary to a drug effect. Acyclovir has
been held. He has also been evaluated by endocrinology prior to
admission and further labs pending inc collagen Ctelopeptide,
repeat bone alkP and SPEP. LFTs today overall stable, alk P
remains elevated. Heme-path eval of liver biopsy still pending.
Likely due to above metastatic prostate danger.
# Trigeminal neuralgia
- continued on gabapentin
# Anemia - Gradually declining Hgb over past few months.
?related to underlying CLL now w/ worsening marrow involvement
vs ibrutinib effect vs prostate CA. No indication for
transfusion at this time.
TRANSITIONAL ISSUES:
1. f/u with Neuro-Oncology and Medical Oncology
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 100 mg PO BID
2. Gabapentin 200 mg PO QHS
3. ibrutinib 140 mg oral DAILY
4. Omeprazole 20 mg PO DAILY
5. biotin 800 mcg oral DAILY
6. Vitamin D ___ UNIT PO DAILY
7. Vitamin B Complex 1 CAP PO DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. loratadine-pseudoephedrine ___ mg oral daily
Discharge Medications:
1. Cyanocobalamin 1000 mcg PO DAILY
2. Gabapentin 100 mg PO BID
3. Gabapentin 200 mg PO QHS
4. Omeprazole 20 mg PO DAILY
5. Vitamin B Complex 1 CAP PO DAILY
6. Vitamin D ___ UNIT PO DAILY
7. bicalutamide 150 mg oral DAILY
RX *bicalutamide 50 mg 3 tablet(s) by mouth daily Disp #*90
Tablet Refills:*0
8. ibrutinib 140 mg oral DAILY
9. biotin 800 mcg oral DAILY
10. loratadine-pseudoephedrine ___ mg oral daily
Discharge Disposition:
Home
Discharge Diagnosis:
Diplopia
Metastatic prostate cancer
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 difficulty seeing. You
were found to have a possible stroke as a cause for your vision
change. You also underwent MRI testing to evaluate for nerve
impingement, with the Radiology Read still pending at time of
discharge. You will follow-up with Dr. ___ for the
final results. You were found to have metastatic prostate cancer
and were started on oral therapy.
Please take your medications as listed.
.
Please follow-up with your doctors as listed.
Followup Instructions:
___
|
10149334-DS-14 | 10,149,334 | 21,389,939 | DS | 14 | 2165-05-07 00:00:00 | 2165-05-07 16:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Zetia
Attending: ___
Chief Complaint:
Fall with R femoral condyle fracture
Major Surgical or Invasive Procedure:
None
History of Present Illness:
As per HPI by admitting MD:
___ with history of NIDDM, neuropathy, chronic ___ wounds, CAD,
CHF, CKD, chronic ulcer on the right foot, HLD, HTN, LLE DVT on
AC presents today as a transfer for a distal femur fracture.
Hx very limited by patient herself d/t delirium but according to
pts dtr who lives with patient; Pt was noted to fall off her
kitchen chair onto her R side last night ___ at approximately
8pm. No loc, headstrike.
No report of changes in mental status, chest pain, shortness of
breath, palpitations, urinary changes including frequency or
dysuria. Per dtr she needs ___ encouragement to drink but there
has been no recent n/v, diarrhea. Pt mostly gets around with
Wheelchair and has been using a walker less.
Pt reportedly stayed on the floor for ~40 mins unable to get up
until pain worsened then called EMS. Pt initially presented to
OSH where distal femur fx of medial condyle involving the
prosthesis fragment of R knee was found (add'l imaging as
below);
transferred here for surgical eval.
Per dtr, pt was seen recently by ___
changing her off-loading dressing (hadn't seen ___ but re-eval
last week as wound re-opened); plan for re-eval next week.
According to dtr; pt is typically alert and orientated 3x but it
is not unusual for her to get confused in the hospital,
especially with pain meds.
Dtr reports ___ gain recently last 1.5 months -?7# and some ___
swelling, but otherwise no changes in breathing or observed
PND/orthopnea.
Pertinent ED course:
Vitals: T 98.7 HR 92 BP 154/117 RR 18 Sp0 98
Labs:
OSH labs: WBC 9.5, Hgb 10.8, Plt 281, INR 2.1, PLT 237
Labs here:
___ 31 Glucose 217
4.2 23 1.2
INR: 1.8 UA: Noninfectious
Ucx: Pending
EKG: ?Afib 106
Exam: Leg shortened and internally rotated, chronic ulcer on the
right foot, 2+ pulses
Meds: Morphine, Fentanyl, Fluoxetine, LR, Allopurinol
Imaging:
========
-X-ray: Status post right knee arthroplasty with an acute
fracture cleft at the right medial femoral condyle. No acute
fracture dislocation of the left knee. X-rays of the tib-fib are
intact.
-CT chest: No evidence of acute intrathoracic injuries, but does
show a 6 mm triangular groundglass opacity at the posterior
aspect of the left lower lobe which is nonspecific, and moderate
central lobar emphysema.
-CT of the abdomen and pelvis:
No acute abnormalities, did show a chronic mild anterior wedge
pressure fracture at L1, and an old S1-S2 fracture. Patient also
had a CT scan of the head which showed no evidence of acute
intracranial injury, with only age-specific changes.
-CT C-spine: No acute cervical spine fractures or
mal-alignments.
Imp/course:
Ortho evaluated the patient in the ED and recommended non
operative management, TDWB, knee immobilizer. ___ with Dr. ___
in 1 week.
___ recommended rehab. Admit for w/u of change in MS and as dtr
unable to private pay for rehab.
Upon arrival to the floor, the patient thought that she was at
home, the year ___. She reported "pressure pain" of R knee and
L
heel
REVIEW OF SYSTEMS (limited by pts encephalopathy; negative
except
as obtained by pts dtr, above)
Past Medical History:
CAD
CHF
Chronic renal insufficiency
Chronic ulcer on the right foot
HLD
HTN
Peripheral neuropathy
Gout
DM
R hip fx
DVT on AC
Social History:
___
Family History:
Reviewed and determined to be non-contributory.
Physical Exam:
ADMISSION:
=========
T 98.5 BP 152 / 68 P 76 RR 18 Spo2 97 RA
GENERAL: Laying in bed, appears state age. HOH. Speaking in full
sentences
EYES: EOMI, PERRL
ENT: OP clear, MM dry
CV: RRR, no mrgs appreciated
RESP: LCTA posteriorly
GI: Abd soft, NTND
GU: No foley
MSK: R leg shortened, internally rotated, immobilizer cast in
place
SKIN: b/l heel ulceration; small area of L arch, large (at least
3x4cm) necrotic area of R arch dressed
NEURO: oriented to person, thought she was at home
PSYCH: Appropriate mood though intermittently confused
DISCHARGE:
=========
T97.9, BP 142/82, HR 81, RR 18, o2 96 RA
Gen - resting comfortably in bed, appears a bit fatigued but
comfortable
HEENT - moist oral mucosa, no OP lesions
___ - RRR, s1/2, no murmurs
Pulm - CTA b/l from anterior, no w/r/r
GI - soft, NT, ND, +BS
Ext - R leg in brace, some tenderness to palpation around knee
where brace is in place. left leg no edema or cyanosis
Skin - warm and dry, no rashes. +3cm firm palpable lesion on
anterior chest (chronic per patient)
Psych - cooperative and calm
Neuro - awake, a bit confused (aaox1-2)
Pertinent Results:
ADMISSION:
=========
___ 02:07AM BLOOD WBC-13.3* RBC-3.34* Hgb-9.7* Hct-30.4*
MCV-91 MCH-29.0 MCHC-31.9* RDW-14.7 RDWSD-48.4* Plt ___
___ 02:07AM BLOOD ___ PTT-28.6 ___
___ 02:07AM BLOOD Glucose-217* UreaN-31* Creat-1.2* Na-140
K-4.2 Cl-105 HCO3-23 AnGap-12
___ 02:07AM BLOOD ALT-10 AST-20 AlkPhos-98 TotBili-0.2
___ 06:10AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.9 Iron-16*
___ 06:10AM BLOOD calTIBC-233* VitB12-425 Hapto-164
Ferritn-48 TRF-179*
___ 06:10AM BLOOD %HbA1c-8.6* eAG-200*
___ 06:10AM BLOOD CRP-80.4*
DISCHARGE:
==========
___ 06:15AM BLOOD WBC-6.9 RBC-3.50* Hgb-10.0* Hct-31.7*
MCV-91 MCH-28.6 MCHC-31.5* RDW-14.8 RDWSD-49.0* Plt ___
___ 06:15AM BLOOD Glucose-164* UreaN-25* Creat-1.2* Na-136
K-4.2 Cl-101 HCO3-25 AnGap-10
Influenza A positive ___
R Knee Xray ___
IMPRESSION:
Redemonstration of a vertically-oriented, minimally displaced
periprosthetic fracture through the medial femoral condyle with
intra-articular extension. The fracture fragment is unchanged in
position compared to prior CT.
Prior:
Smear without schistos
Iron 16, TIBC 233, Ferritin 48
B12 425
Hapto 164, LDH 148
A1c 8.6%
TSH 2.6
CRP 80, ESR 9
UA: neg
UCx (___): negative
IMAGING:
========
TTE (___):
Normal LV wall thickness and biV cavity sizes/regional global
systolic function (EF 65%). Moderate TR. Moderate pHTN.
EKG (___):
NSR at 91 bpm, nl axis, PR 176, QRS 70, QTC 428, early R wave
progression, diffuse T-wave flattening (compared to ___, rate
slower)
X-ray R foot (___):
Limited assessment, due to severe demineralization, and
overlying
soft tissue edema. Mottled appearance of the hindfoot and
tibia,
likely related to demineralization, and no radiographic Findings
of osteomyelitis otherwise. If there is remains high clinical
concern for the diagnosis, may further assess with MRI.
CT RLE (___):
1. Complex fracture with vertically oriented component
extending
through the medial femoral condyle to the articular surface.
Horizontal component extending into the lateral femoral condyle.
2. Lipohemarthrosis.
OSH imaging:
-X-ray: Status post right knee arthroplasty with an acute
fracture cleft at the right medial femoral condyle. No acute
fracture dislocation of the left knee. X-rays of the tib-fib are
intact.
-CT chest: No evidence of acute intrathoracic injuries, but does
show a 6 mm triangular groundglass opacity at the posterior
aspect of the left lower lobe which is nonspecific, and moderate
central lobar emphysema.
-CT of the abdomen and pelvis:
No acute abnormalities, did show a chronic mild anterior wedge
pressure fracture at L1, and an old S1-S2 fracture.
-NCHCT:
No evidence of acute intracranial injury, with only age-specific
changes.
-CT C-spine: No acute cervical spine fractures or
mal-alignments.
Brief Hospital Course:
___ with history of NIDDM c/b neuropathy and b/l plantar ulcers,
CAD, chronic CHF (unclear EF), DVT (on Xarelto), R hip TFN
(___), L hip TFN (___), R TKA (___), CKD stage III, HLD,
HTN presenting as transfer from ___ for fall with R medial
femoral condyle fracture and encephalopathy, with course c/b
acute blood loss anemia and worsening delirium in setting of
newly diagnosed influenza.
# R medial femoral condyle fracture:
# Fall:
-She presented after a fall with R medial femoral condyle
fracture near R knee prosthesis. Per orthopedics, fracture is
non-operative. Fall sounds mechanical by history, with low
suspicion for arrhythmia or ACS. Tele negative. TTE without
significant valvular disease or wall motion abnormalities.
Partial orthostatics negative on admission (limited by R femoral
condyle fracture).
-Repeat xrays ___ did not show any dislocated fragments
-Unlocked ___ brace per orthopedics recs ___
-Tylenol, lidocaine patch, avoid narcotics in the setting of
encephalopathy, also not requiring
-Weight bearing: TDWB
-holding Lasix to avoid orthostasis, volume status appears
stable
-Ortho follow up: scheduled before discharge within the next 1
week
# Encephalopathy:
# Acute delirium:
-Per daughter at baseline she is aaox3 and independent.
Throughout hospitalization she has been aaox1-2 and mental
status has not been significantly different and suspect she has
underlying dementia. Was seen by geriatrics team who recommended
outpatient neurocognitive evaluation. Acute delirium seems to be
resolved, likely was more confused than baseline in the setting
of influenza infection.
#Influenza A
She tested positive ___ and completed a course of Tamiflu
___. Did have some fatigue, malaise and a cough, which seem
to be resolved.
# Normocytic anemia:
# Acute blood loss:
# Concern for GI bleeding:
Hgb 9.7 on admission from 12.2 on ___ downtrended to 7.4 on
___ but then bumped more to 9.7 with only 1u pRBCs on ___.
Suspect contribution from blood loss from long-bone fracture per
ortho, but ___ patient also with one episode of hematochezia
(has known hemorrhoids); No subsequent LGIB. Has not had any
more
reports of bleeding and has had stable CBC and vitals. Was
resumed on her oral anticoagulant without any issues of
bleeding. Can pursue a colonoscopy/further workup as outpatient
if desired.
# Bilateral plantar ulcers:
Likely neuropathic ulcers in setting of poorly controlled DM.
CRP elevated, but no clear evidence of osteomyelitis by exam
(and plain film R foot without clear radiographic evidence).
Wound care made recommendations.
# DM (A1c 8.6%)
Resume home metformin and glyburide upon d/c (Cr 1.2). She was
kept on ISS in the hospital.
# CAD:
- continue home ASA
- continue home atorvastatin
# Chronic HFpEF:
# Moderate pHTN:
-TTE ___ with preserved EF (65%), mod TR, mod pHTN. Appears
euvolemic on exam, holding Lasix because of inability to
ambulate and given stable volume status. Her home potassium
supplements are also held at the time of discharge while her
diuretic remains held.
# HTN:
-BP has been stable. Her atenolol had been held when she had the
isolated episode of hematochezia however resumed as her vitals
stabilized.
# Depression:
- Continue home fluoxetine, which appears to be long-standing
medication; dose reduced to 30mg QHS (from 40mg QHS) given risks
in elderly.
# CKD stage III:
Cr baseline 1.2-1.3, Cr remains stable at 1.2-1.3 (had a
spurious value of 1.0 one time during hospitalization). Holding
Lasix as above.
# Gout:
- continue home allopurinol
# Anxiety:
- hold home Ativan 0.5mg QHS PRN given encephalopathy. Review of
her ___ shows she fills it every few months but has not
filled since ___.
# GOC:
-Per prior covering MD, "patient would be in favor of a trial of
life sustaining measures including CPR and intubation but pt
would not want prolonged life support" - for now will leave as
FC, this will need to be f/u and readdressed as outpatient. She
does not appear able to make decisions about her code status
given what is likely underlying dementia. Her daughter has
recently lost several family members and had a difficult time
with coping, therefore code status discussions were not heavily
pursued.
GENERAL/SUPPORTIVE CARE:
# Nutrition: DM/cardiac diet
# Functional status: TDWB
# VTE prophylaxis: Xarelto
# Advance Care Planning:
- Surrogate/emergency contact: daughter ___ (___)
- Code Status: Full code (would not want sustained long term
life sustaining support)
# Disposition: discharge to rehab today
Time spent: 55 minutes
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Atenolol 25 mg PO BID
4. Furosemide 20 mg PO BID
5. MetFORMIN (Glucophage) 750 mg PO QPM
6. GlyBURIDE 5 mg PO QHS
7. Atorvastatin 40 mg PO QPM
8. Vitamin D Dose is Unknown PO Frequency is Unknown
9. Cyanocobalamin Dose is Unknown PO DAILY
10. FLUoxetine 40 mg PO QHS
11. LORazepam 0.5 mg PO QHS:PRN Anxiety
12. Magnesium Oxide 500 mg PO DAILY
13. Potassium Chloride 10 mEq PO DAILY
14. pyridoxine (vitamin B6) 1 mg oral DAILY
15. Rivaroxaban 20 mg PO QHS
Discharge Medications:
1. Lidocaine 5% Patch 1 PTCH TD QAM
2. Cyanocobalamin 250 mcg PO DAILY
3. FLUoxetine 30 mg PO QHS
4. Vitamin D 1000 UNIT PO DAILY
Please note her home frequency/dosing is unclear
5. Allopurinol ___ mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Atenolol 25 mg PO BID
8. Atorvastatin 40 mg PO QPM
9. GlyBURIDE 5 mg PO QHS
10. Magnesium Oxide 500 mg PO DAILY
11. MetFORMIN (Glucophage) 750 mg PO QPM
12. pyridoxine (vitamin B6) 1 mg oral DAILY
13. Rivaroxaban 20 mg PO QHS
14. HELD- Furosemide 20 mg PO BID This medication was held. Do
not restart Furosemide until you become more active and able to
get up to use the bathroom
15. HELD- LORazepam 0.5 mg PO QHS:PRN Anxiety This medication
was held. Do not restart LORazepam until your mental
status/cognition improves
16. HELD- Potassium Chloride 10 mEq PO DAILY This medication
was held. Do not restart Potassium Chloride until you resume
your diuretic (lasix)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Fall
R femoral condyle fracture
Acute blood loss anemia
Hx DVT
Influenza A infection
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with confusion after a fall
with a right knee fracture. You were seen by orthopedic
surgery, who recommended nonoperative management. You were
noted to be anemic, and received a blood transfusion. You had
one episode of some dark stool but no evidence of a large GI
bleed. You were also treated for the flu in the hospital.
Your confusion improved, and you are being discharged to a
physical rehab facility to regain your strength. We recommend
that you follow up with a neurocognitive specialist to continue
to monitor your cognition.
With best wishes,
___ Medicine
Followup Instructions:
___
|
10149485-DS-10 | 10,149,485 | 21,087,785 | DS | 10 | 2150-05-15 00:00:00 | 2150-05-15 18:43:00 |
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:
right vulvar pain
Major Surgical or Invasive Procedure:
incision and drainage
History of Present Illness:
___ yo undergoing tx for inflammatory breast cancer
transferred from ___ for further management of
abscess. She reports she has noted intermittent fevers since
last
dose of Taxol 2 weeks ago, Tmax ___ yesterday morning. Since
___, she has noted a "bump" on the R mons, increasing in size,
increasingly painful. Today it started spontaneously draining
foul smelling fluid. She went to ___ today for
evaluation, where evaluation was notable for fever of 100.3 at
1300, WBC 24 with left shift and 8 bands.
At ___, she received:
- 1L NS and 650mg Tylenol at 1424
- 1g vanc at 1634
- 3g unasyn at 1504
- ibuprofen 600mg and morphine 4mg at 1523
- Unclear if she was also given Clindamycin
Given size of abscess on clinical exam, ob/gyn recommended
transfer to ___ for further management. She was seen by
surgical consult here, who recommended gyn consult.
On evaluation in ED, she feels fatigued, denies current
fevers/chills. Pain controlled by morphine. No n/v/d. No
parasthesias.
Past Medical History:
OB/GYN: G2P203
- SVD x 1
- C-section x 1 (twins)
PMHx: inflammatory breast cancer on treatment with taxol,
diagnosed in ___, ___ started in ___, med onc at
___, planning mastectomy after neoadjuvant chemo
No h/o hidradenitis or skin disorders. No h/o MRSA infection.
PSH: hysteroscopy for retained IUD, C-section
Social History:
___
Family History:
non contributory
Physical Exam:
Vitals: VSS
Gen: NAD, A&O x 3
CV: RRR
Resp: no acute respiratory distress
Abd: soft, non tender, no rebound/guarding
GU: ~3 inch area of induration consistent with vulvar cellulitis
present on right mons, with packing in place, which is draining
small amount of serosanguinous fluid
Ext: no TTP
Pertinent Results:
___ 05:15AM BLOOD WBC-8.4 RBC-2.80* Hgb-8.2* Hct-25.5*
MCV-91 MCH-29.3 MCHC-32.2 RDW-15.6* RDWSD-50.3* Plt ___
___ 02:56AM BLOOD WBC-12.5* RBC-2.73* Hgb-8.1* Hct-24.8*
MCV-91 MCH-29.7 MCHC-32.7 RDW-15.6* RDWSD-50.4* Plt ___
___ 05:00AM BLOOD WBC-15.0* RBC-2.72* Hgb-7.9* Hct-24.7*
MCV-91 MCH-29.0 MCHC-32.0 RDW-15.6* RDWSD-50.3* Plt ___
___ 06:11AM BLOOD WBC-21.6* RBC-2.78* Hgb-8.2* Hct-25.8*
MCV-93 MCH-29.5 MCHC-31.8* RDW-15.9* RDWSD-52.1* Plt ___
___ 10:25PM BLOOD WBC-19.5* RBC-2.71* Hgb-8.0* Hct-25.0*
MCV-92 MCH-29.5 MCHC-32.0 RDW-15.7* RDWSD-51.5* Plt ___
___ 05:15AM BLOOD Neuts-80* Bands-1 Lymphs-10* Monos-6
Eos-2 Baso-0 ___ Metas-1* Myelos-0 NRBC-1* AbsNeut-6.80*
AbsLymp-0.84* AbsMono-0.50 AbsEos-0.17 AbsBaso-0.00*
___ 02:56AM BLOOD Neuts-80* Bands-1 Lymphs-11* Monos-4*
Eos-1 Baso-0 ___ Metas-2* Myelos-1* NRBC-3* AbsNeut-10.13*
AbsLymp-1.38 AbsMono-0.50 AbsEos-0.13 AbsBaso-0.00*
___ 05:00AM BLOOD Neuts-81* Bands-2 Lymphs-6* Monos-9 Eos-0
Baso-0 ___ Metas-2* Myelos-0 AbsNeut-12.45* AbsLymp-0.90*
AbsMono-1.35* AbsEos-0.00* AbsBaso-0.00*
___ 06:11AM BLOOD Neuts-80* Bands-5 Lymphs-4* Monos-6 Eos-0
Baso-1 Atyps-1* Metas-3* Myelos-0 AbsNeut-18.36* AbsLymp-1.08*
AbsMono-1.30* AbsEos-0.00* AbsBaso-0.22*
___ 10:25PM BLOOD Neuts-84* Bands-8* Lymphs-6* Monos-0
Eos-0 Baso-0 ___ Metas-1* Myelos-1* AbsNeut-17.94*
AbsLymp-1.17* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 05:15AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
Schisto-OCCASIONAL
___ 02:56AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+
Target-OCCASIONAL Tear Dr-1+
___ 06:11AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-1+
___ 10:25PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
___ 05:15AM BLOOD Plt Smr-NORMAL Plt ___
___ 02:56AM BLOOD Plt ___
___ 05:00AM BLOOD Plt Smr-LOW Plt ___
___ 06:11AM BLOOD Plt Smr-LOW Plt ___
___ 10:25PM BLOOD Plt Smr-LOW Plt ___
___ 10:25PM BLOOD ___ PTT-30.3 ___
___ 05:15AM BLOOD Creat-0.6
___ 02:56AM BLOOD Creat-0.6
___ 10:25PM BLOOD Glucose-100 UreaN-7 Creat-0.6 Na-141
K-3.6 Cl-107 HCO3-24 AnGap-14
___ 10:25PM BLOOD estGFR-Using this
___ 10:25PM BLOOD HCG-<5
___ 05:14AM BLOOD Vanco-9.1*
___ 10:35PM BLOOD Lactate-0.8
Brief Hospital Course:
On ___, Ms. ___ was admitted to the gynecology service
with right vulvar swelling concerning for vulvar cellulitis with
underlying abscess. Given concern for infection in the
emergency department, she was started on IV vancomycin and IV
unasyn (___). Her CT scan on ___ was notable for "stranding in
the region of the right labia and groin likely compatible with
cellulitis or inflammation" without "evidence of fluid
collection." A bedside incision and drainage (given clinical
suspicion that infection was coming to a head at site of
abscess) was not able to be tolerated by the patient secondary
to pain. She underwent incision and drainage in the operating
room on ___, with intraoperative findings notable for an area
of right groin cellulitis and right vulvar abscess that was
ulcerated and spontaneously draining. Her wound was packed with
0.25 inch iodoform dressing, and dressings were changed twice
per day until discharge. She was continued on her IV vancomycin
until ___ and on her IV unasyn until ___. She was
transitioned to PO augmentin 875BID for a 14 day course for
discharge.
Of note, she was maintained on ibuprofen, tylenol, and dilaudid
for pain control. Her white blood cell counts and differential
were trended during her stay. She initially had a white count
of 19 with 8 bands on admission, which had improved to 8.4 with
only one band by the time of discharge. Her wound cultures from
___ grew mixed flora and gram negative rods - final cultures
were pending at the time of discharge.
By ___, she was clinically improved, with stable vitals signs,
and pain was controlled with oral medications. She was then
discharged home in stable condition with ___ for once daily
dressing changes and recommendations for infectious disease
follow up and GYN follow up.
Medications on Admission:
taxol infusions q 2 weeks
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours
Disp #*25 Tablet Refills:*1
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1
tablet(s) by mouth every 12 hours Disp #*28 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
per day Disp #*30 Capsule Refills:*1
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Severe
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 4
hours Disp #*10 Tablet Refills:*0
5. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *ibuprofen 800 mg 1 tablet(s) by mouth every 8 hours Disp
#*25 Tablet Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
right vulvar cellulitis with concern for underlying abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the gynecology service with right vulvar
pain and were found to have a right vulvar cellulitis with
concern for an underlying abscess. You underwent incision and
drainage of the infection on ___, and have packing in place.
You were also kept on antibiotics for your infection. You have
recovered well and the team believes you are ready to be
discharged home. You will continue on oral antibiotics at home
(make sure you complete the whole course) and have daily packing
changes. You will follow-up in Dr. ___ office in the next
week. Please call Dr. ___ office with any questions or
concerns. Please follow the instructions below.
We also discussed removal of your Mirena IUD, and placement of a
non-hormonal IUD (Paragard), which will be coordinated as an
outpatient with Dr. ___.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Take a stool softener such as colace while taking narcotics to
prevent constipation.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* You may eat a regular diet.
* You may walk up and down stairs.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No tub baths for 6 weeks.
* A visiting nurse ___ come to change your dressing once per
day at home. You should have your dressing changed once per day
until you see Dr. ___ in the office.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding or abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
10149485-DS-11 | 10,149,485 | 25,049,331 | DS | 11 | 2151-10-11 00:00:00 | 2151-10-11 18:54:00 |
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 arm numbness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old woman with widely metastatic
triple negative breast cancer on palliative
gemcitabine/carboplatin who is admitted from the ED with right
arm parasthesias along with recent fever and URTI symptoms.
She underwent her scheduled D8 gemicitabine therapy last ___.
That evening she developed fever without other localizing
symptoms, and fever was attributed to gemcitabine. The next day
her son developed a cold which she feels she caught. She
developed significant cough and congestion along with a few days
of diarrhea.
She also reports several weeks of waxing and waning paresthesias
around her neck and one episode in her medial thighs. However,
day prior to admission she developed persistent paresthesia
extending from her right neck extending into her distal right
forearm. Given her multiple symptoms she presented to ___
where CT head, CSpine, and LSpine showed bony metastatic
disease.
She was then transferred to ___ ED.
However, she notes no additional fevers since last ___. Her
cough has also resolved and she denies any shortness of breath.
No diarrhea since last night and no abdominal pain. She does
note
reproducible right sided chest discomfort over her right ___ and
4th ribs anteriorly. She also had an episode of emesis after
taking dilaudid on an empty stomach. No other acute complaints.
In the ED, initial VS were T 98.3, HR 66, BP 115/80, RR 19, O2
100%RA. Initial labs notable for Na 143, K 3.9, HCO3 22, Cr 06,
WBC 7.9, HCT 23.0, PLT 30K, INR 1.2. CXR showed no focal
pneumonia. She was given IV Zofran. VS prior to transfer were
pain 7, T 98.3, HR 68, BP 109/70, RR 12, o2 100%RA.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
-___: patient noted rapidly enlarging R breast mass. On
clinical evaluation she was thought to have inflammatory breast
cancer with presence of peau'd orange.
-___: Diagnostic mammogram w CAD - asymmetric confluent
density in RIGHT posterior central breast w/o a discrete mass
with R breast skin thickening concerning for malignancy.
Bilateral axillary lad R>L.
-___: CT CAP and bone scan- no evidence of metastatic dz.
-___: Deemed to have clinical Stage IIIB (cT4dN1) triple
negative inflammatory breast cancer.
-___: GENETIC TESTING-via Quest
lab-BRCAdvantage-comprehensive sequence analysis for BRCA 1 and
2-NEGATIVE.
-___: Neoadjuvant chemo with dose-dense ACX4 followed
by dose-dense taxol X4. The patient tolerated chemo reasonably
well. She had mucositis with Adriamycin. She did have one
infectious complication of a vulvar abscess that was treated
with
I&D and antibiotic. She denies any other infectious
complications. She had myalgias and neuropathy with the taxol.
Her neuropathy resolved after 1 month of chemo.
-___: R mastectomy + ALND-path-residual grade 3 IDC in
dermal, lymphatics with ___ nodes; ypT4dN1a
-___: Post-mastectomy RT-6040cGY under the care of ___ in ___. She had extensive skin toxicity from RT
-___: Bone scan done for patient complaints of diffuse
back pain - no evidence of metastatic dz.
-___: Saw PCP for epigastric pain that led to abdomen US that
showed diffuse metastatic lesions in the liver
-___: CT CAP w contast- numerous new lytic bone lesions;
innumerable liver lesions measuring upto 3.8 cm in the hepatic
dome, concerning for mets. Sigmoid colon circumferential
thickening; non-specific
-___: Bone scan-no focal bone lesion. No diagnostic
scintigraphic evidence of bony metastasis. Findings can be
consistent with diffuse inflammatory breast carcinoma showing as
symmetric bony uptake.
-___: MRI brain w and w/o contrast-No evidence of mets.
Diffuse white matter changes; non-specific, differential
includes
chronic micro-vascular ischemic changes, vasculitis, migraines,
or less likely demyelinating dz or lyme
-___: US guided bx of liver lesion-path-metastatic
adenocarcinoma, c/w breast primary. IHC stains + for CK7 and
GATA-3 and neg for CK20, CDX2, TTF-1, Hep-par
-___: LEFT breast mammogram: Tissue Density D. No evidence
of malignancy in the left breast. BI-RADS 1.
-___: Initial med onc visit at ___. Not eligible for
Cisplatin+ Gedatolisib study ___ AP elevation. Advised to start
standard of care chemotherapy w local oncologist, Dr ___. At
the time patient had back pain ___ bony mets and had reported 10
lb wt loss in 1 mo
-___: C1 Eribulin
-___: C2 Eribulin
-___: C3 Eribulin
-___: CT CAP done at ___ ___ read here)
IMPRESSION:
1. Interval decrease in size of innumerable hepatic metastases,
with new capsular retraction, likely related to treatment effect
(pseudo cirrhosis).
2. Interval increase in size and number of innumerable mixed
lytic and sclerotic osseous metastases.
3. New hazy retroperitoneal soft tissue density at the level of
the origin of the ___. Attention on follow-up is recommended.
4. New right lower lobe ground-glass nodule, likely
infectious/inflammatory. Stable appearing patchy area of
ground-glass density within the right middle lobe, nonspecific.
-___: MRI C and T spine - Mets at C2-4 and all T levels.
-___: CTA Chest at local ER for sob - no PE. bibasilar
atelectasis.
-___: Palliative RT to ?T1-3 and T11?
-___: Foundation CDx testing on prior liver bx-Please see
OMR for full results: MSI stable, Low TMB (tumor mutational
burden), loss of RB and TP53 mutation noted. None of these have
approved treatment.
-___: C1D1 of ___
-___: C1D8 of Gem (gem dose reduced by 20% ___ increased
AST/ALT thought likely ___ gem rather than liver progression
-___: lab check visit showed AST/ALT improving but plt down
to 17K (thought ___ chemo) and improved w/o intervention
-___: C2 delayed ___ ANC 900, neupogen given
-___: C2D1 given w same ___ dose and Gem at 600mg/m2
-___: C2D8 of gem given. Added neulasta on D9
-___: C3D1 of ___
-___: C3D8 (Gem only). On-body neulasta administered on
___: C4D1 ___
-___: C5D1 ___
PAST MEDICAL HISTORY:
1. Breast Cancer, as above
PAST SURGICAL HISTORY:
1. R mastectomy + ___
2. C-section
3. Hysteroscopy
Social History:
___
Family History:
Maternal aunt had ovarian cancer.
Physical Exam:
Temp: 98.1 PO BP: 122/68 Lying HR: 89 RR: 18 O2 sat: 96% O2
delivery: Ra
GENERAL: Pleasant, well appearing young woman sitting up in bed
with her hands clutched to her chest, appears frustrated and
anxious, and occasionally has marked waves of right sided
back and chest pain/spasms.
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Oropharynx clear without lesion, JVD not elevated
CARDIOVASCULAR: Regular rate and rhythm, ___ SEM
RESPIRATORY: Appears in no respiratory distress, Soft BS
throughout which seem decreased BS at bases bilaterally
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding; no hepatomegaly, no
splenomegaly
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Normal bulk. Reproducible point tenderness over
medial right ___ and 3rd ribs, also reproducible point
tenderness
over poseterior 5th rib
NEURO: Alert, oriented. Full ROM of neck and
right arm. Full strength throughout all extremities. Sensation
intact to light touch.
SKIN: No significant rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 03:06AM BLOOD WBC-7.9 RBC-2.34* Hgb-7.4* Hct-23.0*
MCV-98 MCH-31.6 MCHC-32.2 RDW-17.6* RDWSD-62.9* Plt Ct-30*
___ 03:06AM BLOOD Glucose-97 UreaN-4* Creat-0.6 Na-143
K-3.9 Cl-107 HCO3-22 AnGap-14
___ 03:06AM BLOOD ALT-51* AST-44* LD(LDH)-325* AlkPhos-429*
TotBili-0.3
___ 06:16AM BLOOD Calcium-8.7 Phos-4.5 Mg-1.6
MICROBIOLOGY:
=============
___: Blood culture x 2 - PND
___: Urine culture - PND
IMAGING:
========
___ Echo Report
The left atrial volume index is normal. There is normal left
ventricular wall thickness with a normal cavity size. There is
normal regional and global left ventricular systolic function.
Quantitative biplane left ventricular ejection fraction is 59 %.
There is no resting left ventricular outflow tract gradient.
Normal right ventricular cavity size with normal free wall
motion. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender. The aortic arch
diameter is normal. The aortic valve leaflets (3) appear
structurally normal. There is no aortic valve stenosis. There is
no aortic regurgitation. The mitral valve leaflets appear
structurally normal. There is trivial mitral regurgitation. The
tricuspid valve leaflets appear structurally normal. There is
physiologic tricuspid regurgitation. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
___, UNILAT (NO CXR)
No definitive rib fracture identified.
___ T-SPINE W &W/O CONTR
1. Extensive bone metastatic disease. Several more focal
T2/STIR hyperintense lesions previously seen in T4, T6, and T9
are significantly less conspicuous compared to prior study, now
replaced with post-treatment sclerosis. No new focal bone,
paraspinal or epidural mass.
2. No significant spinal canal or foraminal narrowing. No new
pathologic fracture.
3. Right pleural effusion is unchanged or minimally larger since
study from ___. Right basilar consolidation,
likely atelectasis.
___ Imaging CTA CHEST
1. No evidence of pulmonary embolism or aortic abnormality.
2. Trace right pleural effusion with subjacent passive
atelectasis.
3. Diffuse sclerotic osseous metastatic disease as before.
___ Imaging MR HEAD W & W/O CONTRAS
1. No evidence of intraparenchymal metastatic disease.
2. Diffuse marrow signal abnormality in the calvarium and
clivus,
compatible with osseous metastatic disease.
___ Imaging MR ___ W/O CONTR
1. Exam is degraded by motion, particularly postcontrast images.
2. Previously seen lesions in the C2-C3 C4 and C7 vertebral
bodies of either resolved or significantly less prominent
compared with prior, with no definite residual enhancement.
3. No new lesions in the cervical spine concerning for
metastatic
disease.
4. Possible slight residual enhancement in a T1 vertebral body
lesion.
5. Stable degenerative changes at C5-C6 with mild spinal canal
stenosis. Otherwise no significant neural foraminal or spinal
canal stenosis throughout the cervical spine.
___ Imaging UNILAT UP EXT VEINS US
No evidence of deep vein thrombosis in the right upper
extremity.
___ Imaging CHEST (PA & LAT)
No focal findings of pneumonia.
Brief Hospital Course:
PRINCIPLE REASON FOR ADMISSION:
___ is a ___ year old woman with widely metastatic
triple negative breast cancer on palliative
gemcitabine/carboplatin who was admitted from the ED with right
arm, neck, and anterior chest parasthesia and pain along with
recent fever and URTI symptoms. She later developed marked
spasms of pain in right hemithorax radiating from back around to
anterior chest.
MR ___ spine with known osseous mets and increased marrow signal,
but no finding c/w symptoms.CTA chest negative for clot, but did
not small pleural effusion. RUE Doppler negative for clot. MR of
thoracic spine revealed no new mets. Repeat CXR revealed ?
worsening pleural effusion and increased cardiac silhoutte.
Repeat TTE revealed no pericardial effusion. Pulm evaluated her
twice and noted no tappable fluid and the fluid seen on cxr c/w
atalectasis. Unclear if this represents viral pleurisy from
recent URTI or more concerningly, progresion of her breast
cancer. Will need monitoring as outpatient. Her pain was
controlled with her home po dilaudid. We also initiated flexeril
and valium. She still had pain and still would splint. She was
advised to use the IS and ambulate as she spent most of her time
in bed not taking deep breaths in, holding in her cough. She was
not discharged on cough suppressants in attempt to help her
expectorate. She had opiate induced constipation and given mag
citrate and did not want to stay in the hospital any longer to
move her bowels. We suspected her pain and breathing would
improve at home once she would be in an environment that would
encourage her to get OOB.
# Cancer associated anemia
# Thrombocytopenia: She has previously had profound
thrombocytopenia after ___ similar to this, which resolved
without interventions. Fibrinogen, coags, hapto not c/f
consumptive process, and PLT rising by discharge. Transfused 1
unit pRBC ___.
# Fever
# Diarrhea
# URTI: All had resolve by time of admissions. Afebrile this
admission with negative cultures.
# Metastatic triple negative breast cancer
On palliative gemcitabine/carboplatin, most recent C5D1 ___.
She will follow up with Dr. ___.
DISPO: home w/ ___
BILLING: >30 min spent coordinating care for discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
2. Ondansetron 4 mg PO Q6H:PRN nausea
3. Prochlorperazine 10 mg PO Q6H:PRN nausea
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
2. Bisacodyl ___AILY:PRN Constipation - First Line
3. Cyclobenzaprine 10 mg PO TID:PRN Back spasm
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth tid prn Disp #*15
Tablet Refills:*0
4. Diazepam 5 mg PO Q12H:PRN spasm
RX *diazepam 5 mg 1 tab by mouth bid prn Disp #*10 Tablet
Refills:*0
5. Magnesium Citrate 300 mL PO ONCE Duration: 1 Dose
6. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 17 grams by
mouth daily Refills:*0
7. Senna 17.2 mg PO BID
RX *sennosides [senna] 8.6 mg 2 tabs by mouth twice a day Disp
#*120 Tablet Refills:*0
8. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
9. Ondansetron 4 mg PO Q6H:PRN nausea
10. Prochlorperazine 10 mg PO Q6H:PRN nausea
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Pleuritis
# Right pleural effusion
# Metastatic breast cacner
# Cancer associated pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted with right arm, back, and neck
pain. After extensive workup including MRI of your spine, CT
scans, two echocardiograms, two lung ultrasounds, and xrays, we
found that you had inflammation and fluid around the outside of
your lung from lack of taking deep breaths in, causing pain.
Because there was not enough fluid to sample, we cannot tell for
sure what is causing the inflammation, however, it could be due
to a recent viral illness or be related to your known breast
cancer, but seems to be most likely from lack of deep breathing.
We gave you pain medications including dilaudid, flexeril and
valium for extra relief. Please follow up with Dr. ___
will need to keep a close eye on the fluid around the right lung
and your pain.
In addition, you had significant constipation from the
narcotics. please take your bowel medications regularly.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10149624-DS-25 | 10,149,624 | 28,655,127 | DS | 25 | 2136-01-08 00:00:00 | 2136-01-10 02:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Clindamycin / Vancomycin / Asacol
Attending: ___.
Chief Complaint:
UC flare
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F with history of ulcerative colitis and pancreatitis,
presenting with crampy abdominal pain, nausea, diarrhea, bright
red blood per rectum, for the past 6 days. Patient reports onset
of crampy abdominal pain with diarrhea on ___ evening with
associated nausea and vomiting on ___. Began having bright
red blood per rectum and diarrhea every ___ hours starting
___. Symptoms are consistent with her UC flares. Called her
GI doctor on ___ and was started on oral budesonide but
symptoms have not improved. Unable to eat or drink without
resulting in cramping and diarrhea. Last diarrhea was today at
noon, but also states that she had not had any food.
In the ED, initial vitals were 97.6 75 100/59 16 100% RA. Given
4mg IV zofran, 8mg IV morphine, and 20mg IV solumedrol. Patient
complained of abdominal cramping, but no n/v/d. No BM since
today at noon. Guaic +.
Vitals prior to transfer: 98.5 66 100/64 16 100% RA. On arrival
to floor, patient states that she continues to have diffuse
abdominal cramping. Nausea has improved with zofran. No
diarrhea, dizziness, shortness of breath, recent weight loss.
States that she has been very stressed out lately because she
recently turned ___ and she is trying to find a new job.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, dysuria, hematuria.
Past Medical History:
-Ulcerative colitis diagnosed when patient was ___ old and
presented with diarrhea, difficulty keeping po, and vomiting.
Has had ___ hospitalizations since. Last flare was in ___. No
other UC manifestations. She was previously on Asacol in ___
for a couple of months, but stopped taking due to hair falling
out. She has started taking some ___ medicine (mixed of
herbs) since her last flare in ___. Last seen GI doctor ___.
___ in early ___. Last sigmoidoscopy in ___ showing
colitis, and pathology demonstrating chronic-active colitis.
-hx of C. diff in ___ that was treated
-pancreatitis, but only occurring during her flares
-hidradenitis suppurativa
-pancreas divisum
Social History:
___
Family History:
-Grandfather: died of colon cancer
-Mother: healthy, colonic polyps
-Father: borderline diabetes, HTN
-Siblings: healthy
Physical Exam:
ADMISSION PHYSICAL EXAM
VS - 98, 102/66, 84, 18, 100% RA, weight 63.2kg
GENERAL - well-appearing woman, comfortable, in NAD
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, slightly dried
MM, OP clear
NECK - supple, no JVD, no LD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, ND, tender to palpation throughout but
most significantly on L side of abdomen and epigastric area. No
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
DISCHARGE PHYSICAL EXAM
VS - 98.5, 86/50, 60, 20, 98% RA
GENERAL - well-appearing woman, NAD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, ND, tender to deep palpation on L side of
abdomen (mostly LLQ) and epigastric area. No rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, no neuro deficits
Pertinent Results:
ADMISSION LABS
___ 01:49PM BLOOD WBC-6.2 RBC-4.31 Hgb-12.6 Hct-37.7 MCV-87
MCH-29.2 MCHC-33.4 RDW-13.7 Plt ___
___ 01:49PM BLOOD Neuts-48* Bands-0 ___ Monos-14*
Eos-3 Baso-0 ___ Myelos-0
___ 04:30PM BLOOD ESR-11
___ 01:49PM BLOOD Glucose-68* UreaN-7 Creat-0.8 Na-139
K-3.3 Cl-102 HCO3-28 AnGap-12
___ 01:49PM BLOOD ALT-15 AST-18 AlkPhos-58 TotBili-0.3
___ 01:49PM BLOOD Lipase-205*
___ 04:30PM BLOOD Lipase-163*
___ 01:49PM BLOOD Albumin-4.2
___ 01:49PM BLOOD CRP-0.6
DISCHARGE LABS
___ 05:50AM BLOOD WBC-6.7 RBC-4.02* Hgb-11.5* Hct-34.7*
MCV-86 MCH-28.7 MCHC-33.2 RDW-14.1 Plt ___
___ 05:50AM BLOOD Glucose-116* UreaN-8 Creat-0.7 Na-136
K-3.9 Cl-104 HCO3-25 AnGap-11
___ 05:20AM BLOOD Lipase-32
___ 05:50AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.8
___ 05:20AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE IgM HBc-NEGATIVE
___ 05:20AM BLOOD HCV Ab-NEGATIVE
MICRO
___ 1:59 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).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
MANY POLYMORPHONUCLEAR LEUKOCYTES.
FEW RBC'S.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
___ 3:29 pm Immunology (CMV)
**FINAL REPORT ___
CMV Viral Load (Final ___:
CMV DNA not detected.
IMAGING:
___ ABDOMEN (SUPINE & ERECT)
The bowel gas pattern is normal. No evidence of small bowel
obstruction,
differential air-fluid levels, or free intraperitoneal air. No
soft tissue calcifications are noted. There are no acute
osseous abnormalities.
IMPRESSION:
Normal bowel gas pattern. No free intraperitoneal air.
___ CHEST (PA & LAT)
FINDINGS:
The lungs are clear. Mediastinal and cardiac contours are
normal. There is no pleural effusion or pneumothorax.
CONCLUSION:
There are no acute cardiopulmonary findings. There is no
evidence of
infectious process.
Brief Hospital Course:
___ F with history of ulcerative colitis and pancreatitis,
presenting with crampy abdominal pain, n/v, bloody diarrhea
consistent with her previous UC flares.
# UC flare: symptoms presenting similarly to previous UC flares.
ESR and CRP were not elevated, but can be normal in flares.
Differential also included infectious colitis although patient
was without leukocytosis and/or fevers. Stool cultures, O&P,
C.diff, and CMV were sent and were all negative. KUB was
obtained with no signs of toxic megacolon or perforations.
Patient was started on IVF, solumedrol 20mg IV q8h, morphine
___ q4h:prn for pain control, and zofran for nausea. Her
symptoms improved with the steroids and her diarrhea frequency
decreased from every ___ hours to ___ times daily. Her pain also
improved. She was started on a BRAT diet and advanced to
regular. She tolerated the regular diet and at discharge had one
BM that was formed and non-bloody. Nutrition saw the patient
prior to discharge for education regarding UC diet. GI consult
team was involved throughout the hospitalization. Per GI recs,
TB quantiferon, CXR, and hepatitis panel were sent for
preparation for possible need for remicade. TPMT phenotype was
sent for possible need for ___. CXR and hepatitis came back
negative. TB quantiferon and TPMT are still pending. She was
discharged with oral prednisone with plan to start with 40mg po
and decrease by 5 mg each week. She was also discharged with
calcium and vitamin D while on prednisone. Bactrim was not
started as patient stated that she has side effects to bactrim
(GI upset, diarrhea, nausea) and there is plan to taper off
prednisone.
# ? pancreatitis: patient reports that her pancreatitis only
occurs when she has UC flares. Therefore, elevated lipases are
likely a result of abdominal inflammatory changes during her
flares. Lipase on this admission was elevated at 205, however
not diagnostic in the setting of other abdominal process, low
clinical suspicion, and no imaging evidence as per previous CT
abdomen scan during her previous flare in ___. Per GI recs,
trypsin level was sent as it is a more sensitive test for
pancreatitis. By discharge, lipase levels trended down to
normal.
# Hidradenitis suppurativa: stable, predominantly perianally.
Last saw dermatologist on ___ and treated with benzoyl
peroxide wash and topical erythromycin.
# TRANSITIONAL ISSUES
-patient started on prednisone 40mg daily for a week, plan to
decrease dose by 5mg each week
-patient started on vitamin D and calcium while on prednisone.
Bactrim held as patient has side effects to this medication (GI
upset and diarrhea) and there is plan to taper off prednisone
-please follow up with quantiferon-TB gold, trypsin, and TPMT
phenotype
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
2. PredniSONE 10 mg PO DAILY
take prednisone 40mg daily starting ___ for a week, then
decrease dose by 5mg each week: take 35mg from ___, then
down to 30mg from ___, then down to 25mg from ___
and so on.
RX *prednisone 10 mg ___ tablet(s) by mouth daily Disp #*140
Tablet Refills:*0
3. calcium carbonate-vitamin D3 *NF* 500 mg(1,250mg) -400 unit
Oral daily
This medications is to prevent bone loss while you are on
prednisone. Please take daily while you are on prednisone.
RX *calcium carbonate-vitamin D3 500 mg calcium (1,250 mg)-400
unit 1 tablet(s) by mouth daily Disp #*56 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: ulcerative colitis flare
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 abdominal pain and diarrhea that was a
result of a ulcerative colitis flare. You were treated with
steroids and pain medications and your symptoms have improved.
To help control your ulcerative colitis, please take prednisone
40mg daily starting ___ for a week, then decrease dose by
5mg each week: take 35mg from ___, then down to 30mg from
___, then down to 25mg from ___ and so on.
You should take vitamin D and calcium while you are on the
prednisone to prevent possible side effects from the prednisone.
You should stop taking these medications once you finish taking
the prednisone.
Also make sure you follow up with your primary care and GI
doctors.
Followup Instructions:
___
|
10149722-DS-19 | 10,149,722 | 23,479,434 | DS | 19 | 2203-03-10 00:00:00 | 2203-03-11 08:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Diffuse diarrhea, abdominal pain, blood per rectum
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is a ___ F who presented to the ED earlier
yesterday with a one day history of diffuse abdominal pain,
diarrhea with bright red blood, and nausea/vomiting. The pain
___
been diffuse, crampy, and intermittent. She ___ not had any
fevers or chills. She did not eat yesterday because she was not
hungry. Her daughter ___ had similar symptoms, with nausea,
vomiting, and diarrhea. She ___ not lost weight recently.
She was seen in the ED early yesterday evening and left before
full imaging and evaluation could be completed. She returned
several hours later due to worsening pain. The history was
somewhat limited by her expressive aphasia secondary to CVA in
___. Some of her history was provided by her aide.
Past Medical History:
1. s/p ERCP w/ sphincterotomy (sludge w/o stones) (___)
2. CVA w/ residual Right hemipareses and aphasia (___)
3. HTN
4. Hyperlipidemia
5. s/p C-section
6. Osteoporosis
Social History:
___
Family History:
NC
Physical Exam:
On admission:
Temp: 96.3
HR: 96
BP: 144/73
Resp: 16
O2 Sat: 98
GEN: A&Ox3, NAD.
HEENT: No scleral icterus; mucus membranes moist
CV: RRR; no m/r/g.
PULM: Clear to auscultation b/l.
ABD: Soft and mildly distended. Diffusely tender to palpation
throughout abdomen, but less tender in RUQ. Rebound tenderness
and voluntary guarding diffusely. No signs of peritonitis. No
palpable masses.
DRE: Normal tone. Gross blood seen.
Ext: No ___ edema, ___ warm and well perfused.
On discharge:
98.3, 88, 127/81, 16, 95% on room air
Abd: Softly distended, non-tender.
Pertinent Results:
___ 03:57PM BLOOD WBC-10.3 RBC-5.43* Hgb-15.5 Hct-49.5*
MCV-91 MCH-28.6 MCHC-31.4 RDW-13.4 Plt ___
___ 11:35PM BLOOD WBC-13.8* RBC-5.01 Hgb-14.2 Hct-44.4
MCV-89 MCH-28.4 MCHC-32.0 RDW-13.5 Plt ___
___ 10:50AM BLOOD WBC-12.2* RBC-4.28 Hgb-12.3 Hct-37.6
MCV-88 MCH-28.6 MCHC-32.6 RDW-13.8 Plt ___
___ 08:00PM BLOOD WBC-9.5 RBC-4.05* Hgb-12.0 Hct-36.0
MCV-89 MCH-29.6 MCHC-33.2 RDW-13.6 Plt ___
___ 05:02AM BLOOD WBC-10.3 RBC-3.83* Hgb-10.9* Hct-33.5*
MCV-88 MCH-28.4 MCHC-32.4 RDW-13.9 Plt ___
___ 11:35PM BLOOD ___ PTT-29.3 ___
___ 10:50AM BLOOD ___ PTT-31.8 ___
___ 08:00PM BLOOD ___ PTT-28.4 ___
___ 03:57PM BLOOD Glucose-131* UreaN-29* Creat-1.2* Na-143
K-4.9 Cl-104 HCO3-25 AnGap-19
___ 11:35PM BLOOD Glucose-233* UreaN-30* Creat-1.3* Na-137
K-4.8 Cl-98 HCO3-23 AnGap-21*
___ 10:50AM BLOOD Glucose-140* UreaN-21* Creat-0.9 Na-140
K-4.5 Cl-106 HCO3-25 AnGap-14
___ 08:00PM BLOOD Glucose-177* UreaN-15 Creat-0.9 Na-139
K-3.7 Cl-106 HCO3-22 AnGap-15
___ 05:02AM BLOOD Glucose-126* UreaN-13 Creat-0.9 Na-142
K-4.0 Cl-111* HCO3-24 AnGap-11
___ 11:38PM BLOOD Lactate-4.6*
___ 12:52AM BLOOD Lactate-4.3*
___ 02:12AM BLOOD Lactate-4.2*
___ 10:52AM BLOOD Lactate-1.7
___ 08:22PM BLOOD Lactate-1.6
___ 05:36AM BLOOD Lactate-1.0
___: Cdiff negative
___: Ecoli 0157:H7 negative
___: Ova and parasite: negative
___: CT abdomen/pelvis with contrast
1. Mild colitis extending from the mid descending colon to the
rectum. No pneumatosis, extraluminal air, or adjacent fluid
collection. The distribution of colitis favors ischemia as the
etiology, though no arterial or portal venous occlusion is
visualized.
2. The SMA is diminutive but opacifies normally. A large
atherosclerotic calcification is present along the celiac axis
with poststenotic dilatation.
3. Aneurysmal dilatation of left common iliac artery, similar
to prior.
Brief Hospital Course:
Ms. ___ presented to ___ on ___ complaining of diffuse
abdominal pain of sudden onset, blood per rectum, and diarrhea.
On evaluation in the ED, pt was noted to be markedly tender
throughout her abdomen, with lactate to 4.6, WBC to 13. Given
concern for colonic ischemia, pt was admitted to the ICU for
closer monitoring. On arrival in the ICU, pt was kept NPO,
resusitated with IV fluids, and treated empirically with IV
ciprofloxacin and metronidazole for presumptive infectious
colitis. Her urine output was monitor via a foley catheter and
remained adequate throughout her hospital stay.
Ms. ___ responded well to conservative management as noted by
her continued hemodynamic stability, improvement of her
abdominal exam, and downtrending of her lactate by HD#2. Given
this improvement in her clinical appearance, she was transferred
out of the ICU on HD#2 and her diet advanced as tolerated.
During her stay on the medical ward, Mrs. ___ was
hemodynamically stable and afebrile. Her stool cultures were
negative for infectious processes. Blood cultures were pending
at time of this writing. She tolerated oral intake without
pain. She was continued on oral Cipro and Flagyl. She required
no further pain medication.
At time of discharge, Mrs. ___ was in no acute distress and
feeling well. She was discharged with prescriptions for
antibiotics, which will continue for ten days. Follow-up
appointments have been made with both her PCP and the ___
clinic. She will also be going home with ___ services for home
safety purposes, as well as monitoring of her vital signs.
Medications on Admission:
cyclobenzaprine 10 mg 1 tablet PO PRN for neck and shoulder pain
Enablex ___ mg tablet,extended release 1 tablet PO q24h
folic acid 1 mg 1 tablet PO q24h
glipizide ER 5 mg tablet,24 hr extended release 1 tablet PO qAM
Boniva 150 mg 1 tablet PO monthly
Xalatan 0.005 % Eye Drops one drop o.u. daily @ hs
lisinopril 20 mg 1 tablet PO qAM
lorazepam 0.5 mg ___ tablets PO qPM PRN insomnia
metoprolol succinate ER 25 mg 1 tablet PO qAM
Macrodantin 50 mg 1 capsule PO q24h
omeprazole 20 mg capsule,delayed release 2 capsules PO q24h
Oxytrol 3.9 mg/24 hr Transderm Patch. change patch q3days
pramipexole 0.125 mg tablet PO qPM
pravastatin 20 mg 2 tablets PO BID
Tylenol Arthritis 650 mg tablet,extended release 2 tablets BID
PRN knee pain
aspirin 81 mg chewable tablet PO q24h
Calci-Chew 500 mg calcium (1,250 mg) 2 tablets PO q24h
Vitamin B-12 1,000 mcg 1 tablet PO q24h
glucosamine-chondroitin 500 mg-400 mg 2 capsules PO q24h
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 10 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*20 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Enablex *NF* (darifenacin) 15 mg Oral Daily Reason for
Ordering: Wish to maintain preadmission medication while
hospitalized, as there is no acceptable substitute drug product
available on formulary.
5. FoLIC Acid 1 mg PO DAILY
6. GlipiZIDE XL 5 mg PO DAILY
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
8. Metoprolol Succinate XL 25 mg PO DAILY
holdfor HR <60; SBP <110
9. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 10 Days
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*30 Tablet Refills:*0
10. Nitrofurantoin (Macrodantin) 50 mg PO EVERY OTHER DAY
11. Omeprazole 20 mg PO DAILY
12. Pravastatin 20 mg PO DAILY
13. Acetaminophen 325-650 mg PO Q6H:PRN pain
14. Lisinopril 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Ischemic colitis.
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 of abdominal pain.
* You were treated with bowel rest, IV fluids, and IV
antibiotics.
* You responded well to this treatement.
* Your diet was advanced as tolerated without issue.
* You may continue with your regular diet following discharge
from the hospital.
* You should drink plenty of water to stay hydrated.
* You should ambulate frequently to prevent blood clots.
* You should call your primary care physician, or seek immediate
medical attention should you develop abdominal pain, nausea,
fevers, chills, diarrhea, blood per rectum, vomiting, or any
other symptoms which are of concern to you.
* You should continue to take your home medications as before.
* You should continue to take oral antibiotics, ciprofloxacin
and metronidazole, for 10 days.
Followup Instructions:
___
|
10149722-DS-20 | 10,149,722 | 23,451,705 | DS | 20 | 2206-01-21 00:00:00 | 2206-01-28 15:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall with injury
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ s/p unwtinessed fall from standing. Patient uses cane
and ___ Right sided hemiparesis following stroke and ___ had
prior falls. No observed LOC, but patient does not recall
details. Patient complains of pain only on her left side.
Denies CP, SOB. Denies abdominal pain.
Past Medical History:
1. s/p ERCP w/ sphincterotomy (sludge w/o stones) (___)
2. CVA w/ residual Right hemipareses and aphasia (___)
3. HTN
4. Hyperlipidemia
5. s/p C-section
6. Osteoporosis
Social History:
___
Family History:
NC
Physical Exam:
Vitals: HR ___, BP 100s/70s, SpO2 95% on 2L NC
GEN: A&O, NAD
HEENT: mucus membranes moist
CV: RRR
PULM: Clear to auscultation b/l, No W/R/R, breaths unlabored,
left anterior chest wall with some tenderness to palpation, no
crepitus
Breast: left breast with no erythema or tenderness, prior biopsy
site from last month
ABD: Soft, nondistended, nontender, no rebound or guarding no
palpable masses
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 03:35PM GLUCOSE-144* UREA N-22* CREAT-1.1 SODIUM-137
POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-26 ANION GAP-16
___ 03:35PM WBC-12.2*# RBC-4.83 HGB-13.6 HCT-43.4 MCV-90
MCH-28.2 MCHC-31.3* RDW-13.9 RDWSD-45.5
___ 03:35PM WBC-12.2*# RBC-4.83 HGB-13.6 HCT-43.4 MCV-90
MCH-28.2 MCHC-31.3* RDW-13.9 RDWSD-45.5
___ 03:35PM PLT COUNT-152
___ 03:35PM NEUTS-77.1* LYMPHS-13.9* MONOS-6.5 EOS-1.1
BASOS-0.6 IM ___ AbsNeut-9.43* AbsLymp-1.70 AbsMono-0.80
AbsEos-0.14 AbsBaso-0.07
Brief Hospital Course:
Mrs. ___ was admitted to the hospital on ___ after
sustaining a fall with injury to the ___ ribs on the left
side. Her pain was treated accordingly, and her respiratory
function was observed overnight. She was dischrged home in
stable condition with at-home physical therapy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Benzonatate 200 mg PO TID
3. Colchicine 0.6 mg PO BID
4. Cyclobenzaprine 10 mg PO QPM:PRN pain
5. Enablex (darifenacin) 15 mg oral DAILY
6. FoLIC Acid 1 mg PO DAILY
7. GlipiZIDE XL 5 mg PO DAILY
8. Boniva (ibandronate) 150 mg oral monthly
9. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
10. Lisinopril 10 mg PO DAILY
11. Lorazepam 0.5 mg PO QHS:PRN insomnia
12. Metoprolol Succinate XL 50 mg PO DAILY
13. omeprazole 20 mg oral BID
14. Pramipexole 0.125 mg PO QHS
15. Pravastatin 40 mg PO QPM
16. TraMADOL (Ultram) 50 mg PO QHS:PRN pain
17. Aspirin 81 mg PO DAILY
18. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
please hold for loose stool
4. GlipiZIDE XL 5 mg PO DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
do NOT drink alcohol while taking this medication
RX *oxycodone 5 mg 0.5-1.0 tablet(s) by mouth every four (4)
hours Disp #*30 Tablet Refills:*0
9. Senna 8.6 mg PO BID:PRN constipation
10. Lidocaine 5% Patch 1 PTCH TD QAM rib pain Duration: 7 Days
do NOT apply over heart. Apply to area of rib pain
11. TraMADOL (Ultram) 50 mg PO QHS:PRN pain
12. Allopurinol ___ mg PO DAILY
13. Benzonatate 200 mg PO TID
14. Boniva (ibandronate) 150 mg oral monthly
15. Colchicine 0.6 mg PO BID
16. Cyclobenzaprine 10 mg PO QPM:PRN pain
17. Enablex (darifenacin) 15 mg oral DAILY
18. FoLIC Acid 1 mg PO DAILY
19. Lisinopril 10 mg PO DAILY
20. Lorazepam 0.5 mg PO QHS:PRN insomnia
21. Pramipexole 0.125 mg PO QHS
22. Pravastatin 40 mg PO QPM
23. Comode
Patient needs bedside comode x 1 at home.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Fall, left eighth through eleventh non-displaced rib fractures.
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. ___,
You presented to ___ on ___ after suffering a fall. You
sustained left rib fractures and were admitted to the
Trauma/Acute Care Surgery team for further medical care.
You have been scheduled to have Physical Therapy visit you at
home. You are now medically cleared to be discharged to home.
Please note the following discharge instructions:
* Your injury caused left ___ rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
10149765-DS-2 | 10,149,765 | 26,535,625 | DS | 2 | 2131-02-22 00:00:00 | 2131-02-22 11:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Major Surgical or Invasive Procedure:
punch biopsy ___
attach
Pertinent Results:
___
WBC-8.6 RBC-4.04 Hgb-10.7* Hct-33.6* MCV-83 MCH-26.5 MCHC-31.8*
RDW-14.7 RDWSD-44.0 Plt ___
___
Neuts-70.1 Lymphs-17.4* Monos-9.5 Eos-2.1 Baso-0.4 Im ___
AbsNeut-6.00 AbsLymp-1.49 AbsMono-0.81* AbsEos-0.18 AbsBaso-0.03
___
___ PTT-32.1 ___
___
D-Dimer-2317*
___
Glucose-118* UreaN-14 Creat-0.6 Na-139 K-4.3 Cl-104 HCO3-22
AnGap-13
___
ALT-7 AST-22 LD(LDH)-234 AlkPhos-71 TotBili-0.4
___
Calcium-9.2 Phos-3.4 Mg-1.8 UricAcd-5.9*
___
TSH-2.6
___
Blood-NEG Nitrite-NEG Protein-30* Glucose-NEG Ketone-20*
Bilirub-NEG Urobiln-NORMAL pH-6.5 Leuks-TR*
___
URINE RBC-5* WBC-4 Bacteri-NONE Yeast-NONE Epi-6
CTA
TECHNIQUE: Axial multidetector CT images were obtained through
the thorax
after the uneventful administration of intravenous contrast.
Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal
intensity
projection images were submitted to PACS and reviewed.
COMPARISON: None
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified
to the
subsegmental level without filling defect to indicate a
pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of
dissection or
intramural hematoma. The heart, pericardium, and great vessels
are within
normal limits. No substantial pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: There are numerous pathologically
enlarged
lymph nodes. In the axillae, the largest node on the right
measures 2.7 cm in
short axis (2:29), on the left, 1.5 cm (2:33). In the
mediastinum, a
prevascular node measures up to 1.1 cm short axis (2:46). A
subcarinal node
measures up to 1.0 cm (2:52). Conglomerate of bilateral
pathologically
enlarged hilar nodes measure up to 1.2 cm. A pericardial node
measuring 1.1
cm is also present (2:101).
PLEURAL SPACES: Regions of mild nodular enhancement are
demonstrated in the
right anterior pleural, as seen on series 2, image 57 and series
602, image
30). Bilateral pleural effusions, moderate on the right, small
on the left.
LUNGS/AIRWAYS: Ground-glass and irregular opacities are present
bilaterally in
all lobes, greater on the right compared to left.
There is also bibasilar and lingular atelectasis.
There are also several subpleural nodules, measuring 1.4 cm in
the right upper
lobe (3:133), and 1.7 cm in the left lower lobe (3:141).
Additional
subcentimeter ground-glass and solid nodules are present (3:86,
90, 110, 132).
There is mild peribronchial thickening with scattered mucous
plugging.
Lungs are clear without masses or areas of parenchymal
opacification. The
central airways are patent.
BASE OF NECK: Visualized portions of the base of the neck show
1.6 cm right
supraclavicular nodes with associated mass effect in the right
jugular vein
(21:8).1
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES: There are nonspecific cortical irregularities of the
posterior ___
through 6th ribs bilaterally. Otherwise no suspicious osseous
abnormality.?
There is no acute fracture.
SOFT TISSUES: A multilobular heterogeneous enhancing mass in the
right breast
measures approximately 8.2 x 4.5 cm. There is associated
diffuse thickening
of the overlying skin.
IMPRESSION:
1. 8 x 4.5 cm enhancing multilobular right breast mass with
associated skin
thickening, highly suspicious for primary malignancy.
2. Pulmonary nodules and extensive supraclavicular, axillary,
mediastinal, and
hilar lymphadenopathy, concerning for metastatic disease.
3. Scattered bilateral ground-glass and irregular opacities,
concerning for
multifocal pneumonia, possibly superimposed on metastatic
disease.
4. No pulmonary embolism to the subsegmental level.
5. Bilateral moderate-sized pleural effusions, right greater
than left.
Brief Hospital Course:
___ yo F with hx of RA here with new right sided breast mass.
#) Breast mass
Patient was transferred from ___ for breast surgery and onc
eval.
Instead had ___ and IP see her first and patient became very
apprehensive quickly, denying she had cancer and refusing any
intervention.
She ended up having a punch biopsy on ___ which is now pending
on discharge.
Patient is mildly hypoxic on RA to low ___ but not dyspneic. She
was offered thoracentesis but declined because was asymptomatic.
She has follow up with breast surgery and was seen by onc prior
to discharge to establish care and follow up.
There was a question of superimposed infection of the mass. She
had no fevers or leukocytosis. She was discharged with one week
of Bactrim.
Transitional issues
[ ] onc f/u
[ ] breast surgery f/u already made
[ ] IP for ___ if dyspneic due to effusion
[ ] can consider ___ biopsy of contralateral axillary lymph node
Discharge Medications:
1. Sulfameth/Trimethoprim DS 2 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*12 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
New breast mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with a new breast mass which is concerning to
us for a new cancer. You had a biopsy of this and pathology is
pending and we will contact you with this.
There is involvement of the lymph nodes in the chest and armpit.
There are also nodules in the lungs and fluid in the lung
cavities.
You will be called with close follow up with oncology and they
will talk with all the other specialists and decide the next
best course of action.
Followup Instructions:
___
|
10150056-DS-16 | 10,150,056 | 28,370,219 | DS | 16 | 2153-05-28 00:00:00 | 2153-05-29 20:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall, weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMHx diastolic CHF, dementia, who presents to the ED
after a unwitnessed fall. Pt is ___ speaking only. History
was obtained with help of her daughter.
Pt was found down at 2pm on ___ at home by her helper. Pt was
conscious when found. She stated that she felt dizzy prior to
the fall. It is unclear whether pt lost consciousness during the
event, and pt could not recall chest pain or any prodromal
symptoms.
Of note, this is the ___ fall in the past month for Ms.
___. She had a fall a couple weeks ago, and crawled on the
floor for an extended period of time, resulting in multiple
bruises over her legs. Pt received 10 days amoxicillin and
doxycycline, that were finished about one week ago. Per family,
pt denies F/C, CP, SOB, cough, appetite, N/V/D, dysuria. Pt has
good appetite, and her last BM was yesterday, unclear form or
color. family reported that pt gained 12 lbs in the past month.
At baseline, pt needs help with ADL. She lives along with helper
visiting daily.
In the ED, initial VS was 98 83 118/53 20 98%. Hip X-ray showed
small nondisplaced ramus fracture. CXR showed possible increased
opacity in RLL. CT head could not be completed as pt was not
cooperative. Labs were not available at the time of transfer
because of access issues. Pt was given 1 gram Vancomycin for
cellulitis.
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:
CHRONIC BILATERAL PLEURAL EFFUSIONS, S/P TALC PLEURODESIS ___
HYPERTENSION
HYPERLIPIDEMIA
HYPOTHYROIDISM
Gastritis - per EGD ___
H/O NEPHROLITHIASIS
H/O BASAL CELL CARCINOMA ___
CHRONIC CONSTIPATION
URINARY INCONTINENCE
OSTEOPOROSIS
CHRONIC UTI on methenamine
- ___: admitted to ___ for Coombs
positive hemolytic anemia, treated with Solumedrol IV
- ___: bone marrow biopsy with hypercellular marrow with
erythroid hyperplasia and mild non-diagnostic lymphocytosis
- ___: relapsed and was treated with IVIG
- ___: s/p splenectomy by Dr. ___ at ___
___
- ___: hospitalized at ___ for autoimmune hemolytic anemia
with cold agglutinins, received 4 units PRBCs
Social History:
___
Family History:
Mother had hypertension.
Physical Exam:
VS - Temp 97.4F, BP 145/55, HR 78, R 20, O2-sat 96% RA
GENERAL - frail and pale appearing woman in NAD, comfortable,
appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, JVD at clavicle, no carotid
bruits
LUNGS - RLL crackles, no wheeze or rhonchi
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, mildly distended, umbilical hernia, ND on
palpation, no masses or HSM, no rebound/guarding
EXTREMITIES - 1+ pitting edema bilaterally, ___ not palpable,
tender on palpation over left hip
SKIN - multiple shallow ulcers over bilateral shins, mild
erythematous area over right lower leg
NEURO - awake, A&Ox2 (not hospital name), muscle strength ___ in
four extremities, moving both legs well.
VS - 98 130/50 68 17 95%RA
GENERAL - elderly woman, NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, edentulous
NECK - supple, no thyromegaly, JVD at clavicle, no carotid
bruits
LUNGS - CTAB, no wheeze or rhonchi
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, moderately distended, umbilical hernia, ND
on palpation, no masses or HSM, no rebound/guarding
EXTREMITIES - 1+ pitting edema bilaterally, ___ not palpable,
tender on palpation over left hip. R arm and hand with 1+ edema
SKIN - multiple shallow ulcers over bilateral shins, mild
erythematous area over right lower leg, R heel with some
cracking, no obvious ulceration
NEURO - awake, A&Ox3, muscle strength ___ in four extremities,
moving both legs well.
Pertinent Results:
___ 11:00PM BLOOD WBC-7.2 RBC-2.19* Hgb-7.6*# Hct-23.6*
MCV-108* MCH-34.5* MCHC-32.1 RDW-14.2 Plt ___
___ 07:00AM BLOOD WBC-7.1 RBC-2.80* Hgb-9.5* Hct-28.2*
MCV-101* MCH-33.7* MCHC-33.6 RDW-19.0* Plt ___
___ 11:00PM BLOOD Glucose-99 UreaN-103* Creat-1.6* Na-135
K-4.6 Cl-100 HCO3-23 AnGap-17
___ 07:00AM BLOOD Glucose-82 UreaN-95* Creat-1.4* Na-138
K-4.1 Cl-107 HCO3-23 AnGap-12
___:23AM BLOOD LD(LDH)-258*
___ 05:10AM BLOOD proBNP-2283*
___ 05:10AM BLOOD VitB12-GREATER TH
___ 07:23AM BLOOD Hapto-<5*
___ 08:50AM BLOOD Folate-8.2
___ 07:00AM BLOOD TSH-7.0*
___ 07:00AM BLOOD Free T4-0.91*
___ EKG: Sinus rhythm with premature atrial contractions.
Tracing is otherwise within normal limits. Compared to the
previous tracing of ___ the heart rate is increased and the
P-R interval is shortened. Premature atrial contractions are now
noted.
___ ECG: Atrial fibrillation with a rapid ventricular
response. Non-specific ST-T wave changes. Compared to the
previous tracing of ___ atrial fibrillation is new.
___ Hip xray: Possible nondisplaced fracture of the left
superior pubic ramus.
___ CXR: Moderate size right and small left pleural
effusions. Worsening opacification in the right lung base could
reflect compressive atelectasis though infection is difficult to
exclude. Retrocardiac atelectasis.
Brief Hospital Course:
___ with PMHx diastolic CHF, hemolytic anemia, who presents to
the ED after a unwitnessed fall, found to have hemolytic anemia.
# ___: Pt presented with Cr. 1.6 from baseline of 0.7-1. FeUrea
16%, peaked at 2.1, now 1.4. Initially thought ___ anemia and
hypovolemia from increased lasix, however pt appeared volume
overloaded and creatinine worsened with IVF and holding
diuretics. Renal spun urine and saw some yeast and acanthocytes,
wanted to consult, however repeat spin showed only one
acanthocyte, per renal no e/o vasculitis. The pt was restarted
on her home lasix 60mg PO BID and her cr downtrended. On day of
discharge cr was 1.4.
# Weakness: Likely multifactorial, due to deconditioning,
anemia, accidentally doubling her medications at home. Anemia
managed as stated below. ___ worked with pt and felt she would
benefit from rehab. Of note, TSH was elevated at 7 and free T4
0.91. PCP was notified and will follow-up as an outpt.
# Paroxysmal Afib: Pt with baseline sinus rhythm, found to have
afib with RVR for several hours. The pt was started on metop
12.5mg BID with good rate controle, however subsequent reverted
to sinus braycardia. Metoprolol was dced and the pt remained in
normal sinus. Given pt was asymptomatic with afib with rvr,
unclear if this was an isolated event or if she has ongoing
paroxysmal afib. Given the pt's CHADS2 score of 2,
anticoagulation was consider, but felt to be contraindicated in
the setting of her frequent falls. High dose aspirin was also
considered, however pt also with hx of esophageal ulcerations
and ongoing issues with anemia. Pt was continued on aspirin 81mg
daily.
# Anemia: The pt presented with a macrocytic anemia with HCT 23
from baseline of ___, down to 20. The pt has an extensive hx
of hemolytic anemia, and was found to have LDH elevated, hapto
<5, +DAT. GUAIAC negative. She was very difficult to crossmatch
but received 2u prbc with bump to 28. Hemonc was consulted, and
felt she should f/u as an outpatient given her hcts stabilized.
Vitamin B12 greater than assay, folate wnl, however folate 1g
daily started per hem recs.
# s/p fall: Per pt history, likely mechanical, and ___ weakness
from extra medication and anemia. Management of anemia as above.
___ recommended rehab.
# Possible nondisplaced fracture of the left superior pubic
ramus. Pt comfortable, able to ambulate, full ROM. ___ as above.
Should continue lovenox 30mg q24h for DVT ppx while in rehab.
# Funguria: Presented with significant pyuria. Ucx ___. Pt
treated with diflucan 150mg PO x1 per renal recs.
# Heel pain: On day of discharge pt complained of worsening R
heel pain, which, per grandson, has been ongoing for a few
months. Pt has spent a lot of time in bed, and heels appear
slightly cracked and tender, likely applying more pressure than
at baseline. Wound care recs below. Tramadol prn pain. If pain
worsens, can consider outpt eval by podiatry or xray foot.
# Diastolic heart failure: continued home meds. Losartan was
held due to decreased creatinine clearance. Should be restarted
as pt renal function improves, as tolerated by BPs.
# BLE traumatic ulcerations: chronic from crawling on the floor
after prior fall. Wound care evaluated, recs below.
# Asthma: continued home meds
# Hypothyroidism: continued home meds. Of note, TSH was elevated
at 7 and free T4 0.91. PCP was notified and will follow-up as an
outpt.
# HLD: continued home meds
Transitional Issues:
# ___ at rehab
# Followed by PACT for transitions of care: ___ RN,
___
# Pt should have repeat CBC and BUN/cr on ___ and
___ to ensure stability of hct and continued
improvement of renal function
# Pt should f/u with hematology as an outpatient ___
01:30p with Dr. ___
# Pt evaluated by S&S and found to be ok to drink thin liquids.
If has e/o choking/aspirating at rehab, low rehab to recheck.
# Continue Lovenox 30mg q24h for DVT ppx while at rehab given
recent fx.
# Losartan held due to low crcl. Should be restarted as renal
function improves.
# TSH was elevated at 7 and free T4 0.91. PCP was notified and
will follow-up as an outpt.
# If worsening heel pain, could consider podiatry eval or xray
foot
# Wound care should follow pt for ongoing management of her ___
lesions
Recommendations:
Location: Bilateral lower anterior legs
Type: Traumatic ulceration s/p fall
Size: oval shape ulcerations Right 1.5 x 1.5 cm left 2 x 1.5 cm
Wound bed: mixed 50% yellow and 50% pink
Wound edges: left intact
Exudate: oozing clear exudate
Odor: none
___ wound tissue: weeping edematous, two small fluid intact
blisters.
Right medial thigh with approx 1.5 x 0.5 cm unroofed blister
pale pink wound bed and just inferior to this is a small fluid
filled intact blister. Etiology is not known. Patient nurse says
diapers have been used.
Right lateral heel with small intact 2 x 1 cm unstageable
pressure ulcer, 100% intact red tissue. no fluctuance,
or boggy with palpation. Edges attached, ___ wound skin warm
and
+ erythema. Pain is ___ and patient is receiving morphine for
the right heel pain.
Factors affecting wound healing: weeping, pitting edema and
frequent falls at home
Goals of wound care: Topical wound therapy and moisture
management
Recommendations: Pressure relief per pressure ulcer guidelines
Support surface: Atmos Air
Turn and reposition every ___ hours and prn off affected area
Heels off bed surface at all times -
Waffle Boots (X )
If OOB, limit sit time to one hour at a time and
Sit on a pressure redistribution cushion-
Standard Air ( X )
Elevate ___ while sitting.
Moisturize B/L ___ and feet BID
Topical Therapy:
Commercial wound cleanser or normal saline to cleanse wounds.
Pat the tissue dry with dry gauze.
( X )Apply moisture barrier ointment to the ___ wound tissue
with each dressing change.
Change Xeroform to Aquacel AG dressing to all open wounds,
which is antibacterial.
Cover with Sofsorb, and wrap with Kerlix.
Secure with 2" paper tape.
Change dressing daily.
Right lateral heel - daily Adaptic and then cover with 4 x 4 and
wrap with Kerlix.
( X )Apply Spiral Ace Wraps to B/L ___ ( X )
From just above toes to just below knees
Before patient gets OOB or after elevating ___
for ___ minutes prior to application.
Remove ace wraps at bedtime.
No diapers, use large Sofsorb pads under patient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4-6H SOB
per ___, rarely uses
2. fenofibrate nanocrystallized *NF* 145 mg Oral qd
3. Fluticasone Propionate 110mcg 2 PUFF IH DAILY
per ___, uses rarely.
4. Furosemide 60 mg PO BID
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Losartan Potassium 50 mg PO DAILY
7. NIFEdipine CR 90 mg PO DAILY
please hold for SBP < 100 or HR < 60
8. Omeprazole 20 mg PO DAILY
9. Simvastatin 40 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Senna 1 TAB PO BID:PRN constipation
12. Acetaminophen 500 mg PO Q8H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q4-6H SOB
per ___, rarely uses
3. Aspirin 81 mg PO DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH DAILY
per ___, uses rarely.
5. Furosemide 60 mg PO BID
6. Levothyroxine Sodium 88 mcg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Senna 1 TAB PO BID:PRN constipation
9. Simvastatin 40 mg PO DAILY
10. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
11. Docusate Sodium 100 mg PO BID
12. Enoxaparin Sodium 30 mg SC Q24H
please continue while at rehab. Can discontinue once pt
discharged to home.
13. FoLIC Acid 1 mg PO DAILY
14. Miconazole Powder 2% 1 Appl TP BID:PRN groin rash
15. Polyethylene Glycol 17 g PO DAILY:PRN constipatino
16. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
17. NIFEdipine CR 90 mg PO DAILY
please hold for SBP < 100 or HR < 60
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
s/p fall
anemia
___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ was a pleasure participating in your care. You were
admitted for a fall and found to have a small hip fracture. You
were also found to have anemia worse than your baseline, and
worsening kidney function. You were treated with your home
medications and improved. You were also seen by ___ who felt you
would benefit from ___ rehab.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10150136-DS-6 | 10,150,136 | 21,205,678 | DS | 6 | 2126-08-26 00:00:00 | 2126-08-26 19:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypovolemic shock
Major Surgical or Invasive Procedure:
R IJ placement ___
History of Present Illness:
Ms. ___ is a ___ year old F w/ hx of duodenal ulcer, HTN, HLD,
and recently diagnosed a fib presenting with chest pain. Her
symptoms initially started on ___. She was barbecuing and began
to feel nauseated, lightheaded, and very hot. She ate only
watermelon and drank water and then went home. She did not have
any meat or mayonnaise products. She then continued to feel
persistently poor at home with flushing, chest pain, and
difficulty breathing. Two days after that, she went to ___
___. There, she had an EGD and was diagnosed with a
duodenal ulcer and was started on a PPI and an H2 blocker. She
also was diagnosed with new a fib and started on rivaroxaban and
verapamil. She was also started on meloxicam for the chest pain.
Since she has been home, she has been having ___ loose bowel
movements per day. She has been trying to stay hydrated but has
felt very fatigued and like she may pass out. She has not eaten
a good meal in one week. Denies any fevers, chills, black or red
stools, hematemesis, PND, weight gain, ___. She does endorse
some orthopnea. Her chest pain is worst when taking deep breaths
and moving around. Denies productive cough, dysuria, increased
urinary frequency.
In the ED, her vitals showed no fever. She was tachycardic in
the ___ with hypotension with BPs in the ___. She was
saturating well on room air. Her vitals were notable for
worsening tachypnea and dyspnea. She was given 3L NS with no
improvement, so she was started on norepinephrine. Labs notable
for lactate 2.1. Bedside echo appeared to have collapsible IVC
with good cardiac squeeze. CTA chest showed no PE. A foley
catheter was placed for urinary retention. She was given
piperacillin-tazobactam for concern for duodenitis initially,
but this was later re-read as normal. She was also given
Tylenol, potassium, and magnesium. GI was consulted and
recommended continued BID PPI. BP prior to transfer was 100/45.
Upon arrival to the MICU, she is feeling slightly better after
getting IVF. She is very thirsty but not hungry. She is not
currently nauseated. Denies any CP or SOB right now except when
I press on her chest.
Past Medical History:
Atrial fibrillation
Duodenal ulcer
Hypertension
Hyperlipidemia
Pre-diabetes
Mild aortic stenosis
Traumatic brain injury from car crash resulting in depression,
Vertigo
Social History:
___
Family History:
Brother died of ___ lymphoma. Mother died of ___.
Father died of CHF. Nephew with inherited form of renal failure.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T 98.5 HR 73 BP 111/86 RR 22 SPO2 95% RA
GEN: Well appearing middle aged woman sitting up in bed in no
acute distress. Alert and interactive.
HEENT: PERRL. EOMI. No scleral icterus. Dry MM.
NECK: JVP to 12 cm. +HJR
CV: RRR. Nl s1/s2. Grade ___ systolic ejection murmur heard
throughout precordium.
RESP: CTAB. No w/r/r.
CHEST: Tenderness over R chest pain to palpation in front and
back.
GI: Soft. Non-tender. Non-distended. Normoactive bowel sounds.
MSK: Normal muscle tone and bulk
EXT: 1+ pitting edema in ankles bilaterally
SKIN: Warm centrally, cool peripherally. Bruising on upper
extremities.
NEURO: AAOx3. CN II-XII intact. Moves all extremities.
PSYCH: Appropriate affect.
DISCHARGE PHYSICAL EXAM
=========================
VITALS: 24 HR Data (last updated ___ @ 1102)
Temp: 98.1 (Tm 98.6), BP: 101/71 (93-127/66-85), HR: 90
(86-90), RR: 18 (___), O2 sat: 97% (94-98), O2 delivery: Ra
GENERAL: Alert and interactive, NAD.
HEENT: NCAT. PERRL. EOMI. Sclera anicteric and without
injection.
OP clear. MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops.
LUNGS: CTAB. No wheezes, rhonchi or rales. No increased work of
breathing.
ABDOMEN: Obese, mildly distended, ttp in epigastrum and RUQ with
palpation but not with auscultation pressure. BS+.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 grossly intact. AOx3. Sensation and motor
function grossly intact bilaterally
Pertinent Results:
ADMISSION LABS
===============
___ 11:50AM BLOOD WBC-13.3* RBC-3.83* Hgb-10.4* Hct-33.6*
MCV-88 MCH-27.2 MCHC-31.0* RDW-12.8 RDWSD-40.7 Plt ___
___ 11:50AM BLOOD Neuts-79.8* Lymphs-5.6* Monos-12.5
Eos-0.2* Baso-0.5 Im ___ AbsNeut-10.66* AbsLymp-0.74*
AbsMono-1.66* AbsEos-0.02* AbsBaso-0.07
___ 11:50AM BLOOD ___ PTT-32.8 ___
___ 11:50AM BLOOD Glucose-79 UreaN-21* Creat-1.5* Na-131*
K-3.6 Cl-94* HCO3-25 AnGap-12
___ 11:50AM BLOOD ALT-12 AST-19 CK(CPK)-55 AlkPhos-75
TotBili-0.4
___ 11:50AM BLOOD CK-MB-3 proBNP-369*
___ 11:50AM BLOOD Albumin-2.9* Calcium-8.2* Phos-2.9
Mg-1.1*
___ 11:50AM BLOOD Osmolal-269*
___ 11:56AM BLOOD ___ pO2-34* pCO2-47* pH-7.36
calTCO2-28 Base XS-0 Comment-GREEN TOP
___ 11:56AM BLOOD Glucose-79 Lactate-2.1* Creat-1.3*
Na-132* K-3.1* Cl-93* calHCO3-26
INTERVAL LABS
===============
___ 11:50AM BLOOD TSH-2.3
___ 04:19AM BLOOD Cortsol-23.1*
___ 11:50AM BLOOD cTropnT-<0.01
___ 04:42PM BLOOD cTropnT-<0.01
___ 09:20PM BLOOD cTropnT-<0.01
___ 03:43PM BLOOD CK-MB-3 cTropnT-<0.01
___ 11:50AM BLOOD Lipase-29
DISCHARGE LABS
================
___ 05:40AM BLOOD WBC-6.8 RBC-3.09* Hgb-8.4* Hct-28.1*
MCV-91 MCH-27.2 MCHC-29.9* RDW-13.2 RDWSD-43.3 Plt ___
___:40AM BLOOD Glucose-83 UreaN-16 Creat-1.4* Na-137
K-4.5 Cl-102 HCO3-29 AnGap-6*
___ 05:40AM BLOOD Calcium-8.2* Phos-2.7 Mg-1.8
MICRO
=========
Blood cultures - no growth
Urine culture - no growth
IMAGING/STUDIES
=================
CTA CHEST ABDOMEN ___
1. No acute intra-abdominal or intrapelvic process.
2. No evidence of pulmonary embolism.
3. Fibroid uterus.
4. Diverticulosis without evidence of diverticulitis.
CXR ___
No acute cardiopulmonary process, no change since exam from
earlier the same day.
TTE ___
The left atrial volume index is mildly increased. The right
atrium is mildly enlarged. 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 hyperdynamic. The visually
estimated left ventricular ejection fraction is 80%. Left
ventricular cardiac index is normal (>2.5 L/ min/m2). There is
no resting left ventricular outflow tract gradient. Normal right
ventricular cavity size with hyperdynamic free wall motion. The
aortic sinus diameter is normal for gender with mildly dilated
ascending aorta. There is no evidence for an aortic arch
coarctation. The aortic valve leaflets (?#) are mildly
thickened. There is no aortic valve stenosis. The increased
velocity is due to high stroke volume. There is no aortic
regurgitation. The mitral valve leaflets are mildly thickened
with no mitral valve prolapse. There is trivial mitral
regurgitation. The pulmonic valve leaflets are normal. The
tricuspid valve leaflets appear structurally normal. There is
physiologic tricuspid regurgitation. The estimated pulmonary
artery systolic pressure is normal. There is a very small
pericardial effusion. There are no 2D or Doppler
echocardiographic evidence of tamponade.
IMPRESSION: Suboptimal image quality. Hyperdynamic biventricular
systolic function.
KUB ___
Mild colonic distension, perhaps slight ileus that seems to be
improving
common association with suspected recent colitis at the splenic
flexure,
possibly ischemic colitis, based on review of the CT. No
evidence of
obstruction.
CT Abd with contrast ___
1. Oral contrast is seen extending to loops of jejunum without
evidence of
extraluminal contrast or free intraperitoneal air to suggest
perforation.
2. No evidence of duodenal wall thickening or adjacent soft
tissue stranding
to suggest an inflammatory infectious process. No evidence of
peripancreatic
edema or stranding.
Brief Hospital Course:
TRANSITIONAL ISSUES:
=================================
[] ___ consider stool studies for further diagnostic clarity if
diarrhea persistent.
[] ___ consider thorough investigation of depression given
history of passive suicidality in statements made to sister.
[] outpatient GI f/u ___ weeks for repeat EGD.
[] Patient discharged on xarelto. Would follow up with her
regarding tolerance and compliance with taking medication with
largest meal of day.
[] Verapamil, HCTZ, and lisinopril held at discharge, may
consider re-starting pending blood pressure.
[] ___ consider further work-up of normocytic anemia.
MEDICATIONS:
- New Meds: rivaroxaban
- Stopped Meds: verapamil, hydrochlorothiazide, lisinopril
- Changed Meds:
FOLLOW-UP
- Follow up: PCP ___ ___ days
OTHER ISSUES:
- Discharge Hemoglobin: 8.4
- Discharge Cr: 1.4
# CODE: DNR/DNI
# CONTACT: ___ - ___
BRIEF HOSPITAL COURSE
===================
Ms. ___ is a ___ woman with a recent diagnosis of a duodenal
ulcer, paroxysmal atrial fibrillation, traumatic brain injury,
hypertension, hyperlipidemia admitted with hypotension
attributed to hypovolemia secondary to diarrhea caused by likely
duodenitis. She initially presented to the ED with
light-headedness, found to be hypotensive with systolic
pressures in the ___ fluid unresponsive, so she was initiated on
norepinephrine.Given Zosyn due to concern for duodenitis from
the preliminary read of a chest CTA. Gastroenterology
recommended twice daily PPI. Admitted to MICU for pressor
support. Able to wean off pressors on ___. Etiology of
hypotension deemed most likely secondary to hypovolemic shock
from persistent two weeks of diarrhea, poor PO intake, and
antihypertensives/laxatives. Persistent abdominal pain
attributed to her duodenal ulcer diagnosed by EGD at outside
hospital. Abdominal imaging negative for any perforation, free
air, or obstruction, though per radiology may have had a mild
ischemic colitis at splenic flexure in setting of her
hypotension. She was transferred to the floor where her blood
pressure remained stable with intermittent IVF, stool studies
were negative for C. Diff and other pathogens, and her abdominal
pain was somewhat controlled with IV dilaudid and oxycodone
which was discontinued by time of discharge. She was started on
apixaban for atrial fibrillation, which had returned to sinus by
time of discharge. Discharged on xarelto due to having previous
prescription at home from OSH.
PROBLEM LIST:
============
#Duodenal Ulcer
#Abdominal Pain
Continued abdominal pain, primarily epigastric, in setting of
recent EGD performed at ___ demonstrating two flat
duodenal ulcers. Per radiology, CT Abdomen on ___ have shown
mild ischemic colitis at splenic flexure, likely in setting of
her hypotension. Repeat CT Abd with contrast showed no evidence
of perforation, free air, or obstruction. She was given magic
mouthwash, pantoprazole 40mg BID, ranitidine 150mg PO QHS, and
sucralfate 1g PO QID. Pain controlled with intermittent dilaudid
and oxycodone 5mg PO Q6:PRN for pain.
#Diarrhea
Believed to be related to duodenitis. No recent history of
antibiotic use. Thought to have been contributing to her initial
hypotension. Improved on maximal doses of loperamide. Stool
studies: C. Diff negative, other studies showed no growth.
#Depression
Continued on home venlafaxine. Per sister, patient has had
feelings of guilt since her brother's death, wishing she had
passed away instead. Has previously told her sister that she
"just wants to die." Per patient, not endorsing depression or
suicidality. She was monitored carefully during her hospital
stay and required no psychiatric consult.
#Atrial fibrillation
Appears to be paroxysmal. Recently diagnosis at OSH. CHADS2VASC2
score of 2. Verapamil was held and rates remained near 80 during
ICU course in setting of hypotension. Apixaban 5mg BID started
on ___ and switched to xarelto due to previous prescription at
OSH.
#Coagulopathy
Unclear baseline. ___ be secondary to recent xarelto use. No
liver abnormalities on labs or imaging. INR - 1.4 at last check
___.
#Normocytic Anemia
Unclear baseline, but denies known history of this. ___ be
secondary to duodenal ulcer. Sturdy Hospital records - Hgb 10.0.
___ consider additional work-up as outpatient.
#Pleuritic chest pain
Likely musculoskeletal course given trops negative and EKG
non-ischemic, and there is no PE, AAA, pericardial effusion, or
rib fractures on imaging. History nor EKG consistent with
pericarditis. ___ be secondary to duodenal ulcer as well.
Improved by time of discharge with pain medications as above.
#Acute kidney injury
Cr 1.3 on transfer, down from 1.5 on presentation. Unclear
baseline. Unknown if any contribution from CKD. Stable at 1.4.
#Poor caloric intake, at risk for malnutrition
Nutrition consulted. Given ensure enlive TID.
#HTN
Home HCTZ, Lisinopril, and verapamil held in the setting of
recent hypotension.
RESOLVED ISSUES
===============
#Hypotension
Felt to be secondary to hypovolemia from diarrhea and poor PO
intake. Improved with IVF. No evidence of infection. Brief
period requiring levophed in ICU, off pressors ___. Blood
cultures NGTD, urine culture NGTD. Fluid responsive while on
floor.
#Hyponatremia
___ have been secondary to hypovolemia and poor PO intake given
low serum osmolality. Improved with fluid intake.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sucralfate 1 gm PO QID
2. Rivaroxaban 20 mg PO DAILY
3. Verapamil SR 240 mg PO Q24H
4. Pantoprazole 40 mg PO Q12H
5. Ranitidine 150 mg PO QHS
6. Atorvastatin 80 mg PO QPM
7. Hydrochlorothiazide 25 mg PO DAILY
8. Nortriptyline 25 mg PO QHS
9. Promethazine 12.5 mg PO BID:PRN nausea
10. Venlafaxine XR 150 mg PO DAILY
11. HydrOXYzine 25 mg PO BID
12. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg 2 tablet(s) by mouth Q8h: PRN Disp #*90
Tablet Refills:*0
2. LOPERamide 2 mg PO QID
RX *loperamide [Anti-Diarrheal (loperamide)] 2 mg 2 mg by mouth
four times a day Disp #*120 Tablet Refills:*0
3. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN
Reflux/Abdominal Pain
RX *alum-mag hydroxide-simeth [Maalox Maximum Strength] 400
mg-400 mg-40 mg/5 mL ___ ml by mouth QID:PRN Refills:*0
4. Atorvastatin 80 mg PO QPM
5. HydrOXYzine 25 mg PO BID
6. Nortriptyline 25 mg PO QHS
7. Pantoprazole 40 mg PO Q12H
8. Promethazine 12.5 mg PO BID:PRN nausea
9. Ranitidine 150 mg PO QHS
10. Rivaroxaban 20 mg PO DAILY
11. Sucralfate 1 gm PO QID
12. Venlafaxine XR 150 mg PO DAILY
13. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until you see your
PCP
14. HELD- Lisinopril 10 mg PO DAILY This medication was held.
Do not restart Lisinopril until you see your PCP
15. HELD- Verapamil SR 240 mg PO Q24H This medication was held.
Do not restart Verapamil SR until you see your pcp
___:
Home With Service
Facility:
___.
Discharge Diagnosis:
PRIMARY DIAGNOSES
================
- Duodenal ulcers
- Hypotension secondary to hypovolemia
- Diarrhea
- Paroxysmal atrial fibrillation
SECONDARY DIAGNOSES
===================
- Depression
- Anemia
- Coagulopathy
- Hyponatremia
- Acute kidney injury
- Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted because you were having chest and abdominal
pain. Your blood pressure was also very low.
What was done for me while I was in the hospital?
- You were started on pain medications to help with your pain.
- You were transferred for higher level care to the intensive
care unit to manage your low blood pressure.
- You underwent imaging that reassured your health care
providers that your bowel did not have a hole in it, and that
your abdominal pain is likely caused by your ulcers.
- You were given medications to help reduce your diarrhea.
- You were started on a medication to prevent clots caused by an
abnormal heart rhythm.
What should I do when I leave the hospital?
- Continue to take your medications as prescibed and be sure to
attend appointments with your PCP as listed.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10150167-DS-7 | 10,150,167 | 25,951,281 | DS | 7 | 2128-02-05 00:00:00 | 2128-02-05 16:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
promethazine / benzonatate / Influenza Virus Vaccines /
prednisone / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy.
2. Closure of perforation with omental patch.
3. Gastrostomy tube.
History of Present Illness:
Ms. ___ is a ___ years old woman with past medical history of
osteoarthritis, COPD and Roux-en-Y gastric bypass ___
-___ who is transferred from OSH for severe abdominal pain
and CT scan showing specs of intraabdominal free air.
Patient presented this morning to OSH with sudden onset
abdominal pain and transferred for perforated viscous. Patient
reports pain was severe and woke her up from sleep. Reports the
pain was 10 out of 10 on arrival to outside hospital and after
pain medication, the pain improved to 4 out of 10. Reports her
mouth feels very dry. Denies vomiting, fever, chills, dysuria.
Reports the pain is mostly in her upper abdomen across the
epigastrium into the left upper abdomen to the left breast.
Denies any history of similar pain. Reports the pain is worse
with lying flat. Reports had a small but normal bowel movement
this morning that did not change her pain. In the OSH, patient
received a dose of vancomycin and zosyn and IV morphin and
fentanyl for pain control and was transferred to ___.
Upon further questioning it was noted that patient is on Relafen
for her osteoarthritis which raises suspicion for perforated
ulcer.
In the ED patient is mildly tachycardic, her pain is better
controlled but her abdomen is tender to palpation in epigastrium
and left upper abdomen.
Past Medical History:
Morbid obesity
Osteoarthritis
Asthma
COPD not on home O2
Depression
UTI
PSH:
Roux-en-Y gastric bypass ___ - Dr. ___
Bilateral knee replacements
Bilateral shoulder replacements
Social History:
___
Family History:
Mother: obesity, heart disease
Physical Exam:
GEN: NAD
HEENT: NCAT
CV: RRR
PULM: no respiratory distress
ABD: soft, distended, incisions C/D/I
EXT: warm, well-perfused
WOUND(S): Incision c/d/i
DRAINS: none
Pertinent Results:
Please see OMR for pertinent results.
Brief Hospital Course:
Ms. ___ is a ___ s/p RNY gastric bypass ___ who was
transferred to ___ from an outside hospital after presenting
with abrupt onset of abdominal pain with an abdominal CT scan
suggestive of a perforated marginal ulcer in the setting of
daily NSAID use. Given CT scan, physical exam findings and
leukocytosis, the patient was taken to the operating room where
she underwent an exploratory laparotomy, closure of perforation
with omental patch and placement of a gastrostomy tube. Of
note, the patient was hypotensive in the operating room
requiring transient pressors; please see operative note for
details. Post-procedure, the patient was extubated and was taken
to the surgical intensive care unit for close monitoring where
she remained until POD2 and was subsequently transferred to the
general surgical ward for the remainder of her hospitalization.
Neuro: The patient experienced intermittent delirium in the ICU,
which resolved upon transfer to the floor where she remained
alert and oriented throughout the remainder of her
hospitalization; pain was initially managed with a morphine PCA
and intravenous acetaminophen. Once tolerating an oral diet,
pain management was transitioned to oral oxycodone and
acetaminophen. Her home fluoxetine was resumed on POD8.
CV: The patient remained stable from a cardiovascular
standpoint, but was intermittently tachycardic (low 100s
increased with physical activity) with an episode of SVT in the
ICU which was managed with intravenous metoprolol. She also had
two episodes of asymptomatic non-sustained ventricular
tachycardia up to 10 beats on POD3 and again on POD4; ECG
without changes and electrolytes were monitored and repleted as
needed. Vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; she received nebulizer treatments prn and continued
her home Advair BID; 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 with a
___ tube and gastrostomy tube in place for
decompression. On POD1, a PICC was placed and TPN was
initiated. The ___ tube was kept in place through
POD3; an UGI performed the following day was negative for a
leak, therefore, the diet was progressively advanced to a
bariatric stage III diet which was well tolerated. PICC/TPN was
discontinued on POD 6 after the patient developed a
non-occlusive thrombus is the right basilic vein. The
gastrostomy and JP drain was removed on the day of discharge.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none. Intravenous Zosyn was
administered for two days post-operatively and transitioned to
Unasyn which was given through POD8. Of note, the patient
developed a drug rash on her lower extremities after receiving
intravenous metronidazole and ceftriaxone x 1 which was resolved
after these medications were discontinued.
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.
REHAB: The patient was evaluated by the Physical Therapist who
recommended acute rehab; please see ___ note for details.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Tolterodine 4 mg PO DAILY
2. Ipratropium-Albuterol Neb 1 NEB NEB Q6H AS DIR
3. clotrimazole-betamethasone ___ % topical ASDIR
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Nabumetone 750 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. albuterol sulfate 90 mcg/actuation inhalation ASDIR
8. FLUoxetine 20 mg PO BID
9. nitrofurantoin macrocrystal 50 mg oral DAILY
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
2. Bisacodyl ___AILY:PRN Constipation - First Line
3. Docusate Sodium (Liquid) 100 mg PO BID
4. Heparin 5000 UNIT SC TID
5. Multivitamins W/minerals Chewable 1 TAB PO BID
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
7. Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line
flush
8. Vitamin D 1000 UNIT PO DAILY
9. Zinc Sulfate 220 mg PO DAILY
10. albuterol sulfate 90 mcg/actuation inhalation ASDIR
11. clotrimazole-betamethasone ___ % topical ASDIR
12. FLUoxetine 20 mg PO BID
13. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
14. Ipratropium-Albuterol Neb 1 NEB NEB Q6H AS DIR
15. nitrofurantoin macrocrystal 50 mg oral DAILY
16. Tolterodine 4 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Perforated marginal 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 the hospital with a perforated marginal
ulcer, recovered in the hospital and are now preparing for
discharge to ___ in ___.
Please note the following instructions:
Please call your surgeon or return to the Emergency Department
if you develop a fever greater than ___ F, shaking chills, chest
pain, difficulty breathing, pain with breathing, cough, a rapid
heartbeat, dizziness, severe abdominal pain, pain unrelieved by
your pain medication, a change in the nature or severity of your
pain, severe nausea, vomiting, abdominal bloating, severe
diarrhea, inability to eat or drink, foul smelling or colorful
drainage from your incisions, redness, swelling from your
incisions, or any other symptoms which are concerning to you.
Diet: Stay on Stage III diet until your follow up appointment
Medication Instructions:
Please refer to the medication list provided with your discharge
paperwork for detailed instruction regarding your home and newly
prescribed medications.
Some of the new medications you will be taking include:
1. Pain medication: You will receive a prescription for liquid
oxycodone, an opioid pain medication. This medication will make
you drowsy and impair your ability to drive a motor vehicle or
operate machinery safely. You MUST refrain from such activities
while taking these medications. You may also take acetaminophen
(Tylenol) for pain management; do not exceed 4000 mg per 24 hour
period.
2. Constipation: This is a common side effect of opioid pain
medication. If you experience constipation, please reduce or
eliminate opioid pain medication. You may trial 2 ounces of
light prune juice and/or a stool softener (i.e. crushed docusate
sodium tablets), twice daily until you resume a normal bowel
pattern. Please stop taking this medication if you develop
loose stools. Please do not begin taking laxatives including
until you have discussed it with your nurse or surgeon.
3. Antacids: You will continue taking omeprazole daily.
4. You must not use NSAIDS (non-steroidal anti-inflammatory
drugs). Examples include, but are not limited to Aleve,
Arthrotec, aspirin, Bufferin, diclofenac, Ecotrin, etodolac,
ibuprofen, Indocin, indomethacin, Feldene, ketorolac,
meclofenamate, meloxicam, Midol, Motrin, nambumetone, Naprosyn,
Naproxen, Nuprin, oxaprozin, Piroxicam, Relafen, Toradol and
Voltaren. These agents may cause bleeding and ulcers in your
digestive system. If you are unclear whether a medication is
considered an NSAID, please ask call your nurse or ask your
pharmacist.
5. Vitamins/ minerals: You may resume a chewable multivitamin,
however, please discuss when to resume additional vitamin and
mineral supplements with your bariatric dietitian.
Activity:
You should continue walking frequently throughout the day right
after surgery; you may climb stairs.
You may resume moderate exercise at your discretion, but avoid
performing abdominal exercises or lifting items greater than10
to 15 pounds for six weeks.
Wound Care:
You may remove any remaining gauze from over your incisions.
You will have thin paper strips (Steri-Strips) over your
incision; please, remove any remaining Steri-Strip seven to 10
days after surgery.
You may shower 48 hours following your surgery; avoid scrubbing
your incisions and gently pat them dry. Avoid tub baths or
swimming until cleared by your surgeon.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Please call the doctor if you have increased pain, swelling,
redness, cloudy, bloody or foul smelling drainage from the
incision sites.
Avoid direct sun exposure to the incision area for up to 24
months.
Do not use any ointments on the incision unless you were told
otherwise.
Followup Instructions:
___
|
10150279-DS-9 | 10,150,279 | 29,054,774 | DS | 9 | 2143-09-20 00:00:00 | 2143-09-23 23:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Vicodin / morphine
Attending: ___.
Chief Complaint:
Small bowel obstruction
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: ___ with Stage IV rectal cancer s/p chemoradiation and
cyberknife therapy as well as abdominoperineal resection by Dr.
___ in ___ and liver wedge resections for
metastasis on ___ who presents now with one day of nausea,
vomiting and abdominal pain. She reports doing well since
discharge from her most recent hospitalization for liver hepatic
resection on ___. She was tolerating a diet and had resumed
her usual activities. She experienced rather abrupt onset
nausea
and vomiting accompanied by sharp and crampy mid abdominal pain
around 4:30 ___ last night. The vomiting continued approximately
once every hour overnight and slowed slightly into this AM when
she went to ___. She notes her ostomy stopped
putting out as of last evening as well. She denies bloating or
current nausea, though she did get zofran on arrival.
Past Medical History:
PMH: rectal cancer s/p neoadjuvant therapy, APR, and cyber knife
for positive margins, DVT in upper neck ( from port a cath),
morbid obesity, HTN, HL, GERD, osteoporosis, and restless leg
syndrome
PSH: APR w/ advancement flap ___ (___), caudate
lobe/segment 5 wedge resection ___ (___), laparoscopic
appendectomy ___, right knee surgery in ___, laparoscopic
cholecystectomy 1990s
Social History:
___
Family History:
noncontributory
Physical Exam:
___ with Stage IV rectal cancer s/p chemoradiation and
cyberknife therapy as well as abdominoperineal resection by Dr.
___ in ___ and liver wedge resections for
metastasis on ___ who presents now with one day of nausea,
vomiting and abdominal pain. She reports doing well since
discharge from her most recent hospitalization for liver hepatic
resection on ___. She was tolerating a diet and had resumed
her usual activities. She experienced rather abrupt onset
nausea
and vomiting accompanied by sharp and crampy mid abdominal pain
around 4:30 ___ last night. The vomiting continued approximately
once every hour overnight and slowed slightly into this AM when
she went to ___. She notes her ostomy stopped
putting out as of last evening as well. She denies bloating or
current nausea, though she did get zofran on arrival.
Pertinent Results:
___ 12:30PM ___ PTT-29.9 ___
___ 12:30PM PLT COUNT-459*#
___ 12:30PM NEUTS-86.8* LYMPHS-7.4* MONOS-5.5 EOS-0.1
BASOS-0.1
___ 12:30PM WBC-11.7*# RBC-3.99*# HGB-10.7*# HCT-33.5*#
MCV-84 MCH-26.9* MCHC-32.0 RDW-15.0
___ 12:30PM ALBUMIN-3.7
___ 12:30PM ALT(SGPT)-38 AST(SGOT)-27 ALK PHOS-210* TOT
BILI-1.0
___ 12:30PM estGFR-Using this
___ 12:30PM GLUCOSE-106* UREA N-11 CREAT-0.6 SODIUM-138
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-25 ANION GAP-17
___ 12:43PM LACTATE-1.6
___ 12:43PM COMMENTS-GREEN TOP
CT a/p ___
IMPRESSION:
1. Dilated proximal small bowel that tapers distally with
relative transition
in the left lower quadrant with collapsed distal bowel,
compatible with small
bowel obstruction. Mild edema may be present at the location of
relative
transition in the distal small bowel.
2. 11.8 x 7.9 cm complex right hepatic lobe heterogeneous
collection, which
may be normal in the setting of recent segment V wedge
resection, but please
correlate for infection, especially given amount of fluid and
foci of air
within this collection. This collection would be amenable to
drainage.
3. Status post left lower quadrant colostomy with decreased
size of anterior
abdominal wall subcutaneous postoperative seroma. Perineal
postoperative
seroma has also decreased in size.
Brief Hospital Course:
___ yo F with hx of rectal ca w/ liver mets s/p APR (___) and ex
lap with wedge resection of caudate lobe and segment 5 (___)
presented with SBO ___ that was managed conservatively with
NPO/IVF. A CT scan showed was concerning for an obstruction
without a clear transition point. It also showed a liver fluid
collection that Transplant surgey throught to be post-surgical.
On HD1, her ostomy began putting out stool and gas. Her diet was
advanved to clears. On HD2, she was advanced to regular diet and
tolerated it without nausea/emesis. A wound care consult was
called for left gluteal unstageable pressure ulcer with partial
thickness opening and eschar. This area was managed with
mepilex. Her staples were removed on HD2 and she was discharged
home with ___.
On ___, the patient was discharged to home with ___. At
discharge, he/she was tolerating a regular diet, passing flatus,
stooling?, voiding, and ambulating independently? He/She will
follow-up in the clinic in ___ weeks. This information was
communicated to the patient directly prior to discharge.
Include in Brief Hospital Course for Every Patient and check of
boxes that apply:
Post-Surgical Complications During Inpatient Admission:
[ ] Post-Operative Ileus resolving w/o NGT
[ ] Post-Operative Ileus requiring management with NGT
[ ] UTI
[ ] Wound Infection
[ ] Anastomotic Leak
[ ] Staple Line Bleed
[ ] Congestive Heart failure
[ ] ARF
[ ] Acute Urinary retention, failure to void after Foley D/C'd
[ ] Acute Urinary Retention requiring discharge with Foley
Catheter
[ ] DVT
[ ] Pneumonia
[ ] Abscess
[x] None
Social Issues Causing a Delay in Discharge:
[ ] Delay in organization of ___ services
[ ] Difficulty finding appropriate rehabilitation hospital
disposition.
[ ] Lack of insurance coverage for ___ services
[ ] Lack of insurance coverage for prescribed medications.
[ ] Family not agreeable to discharge plan.
[ ] Patient knowledge deficit related to ileostomy delaying
discharge.
[x] No social factors contributing in delay of discharge.
Medications on Admission:
Sertraline 50HS', ativan 0.5 prn, colace 100', coumadin 10mg
(___) 12.5 mg (___), klor-con 20meq daily, maxzide
___ 1 tab daily, slow mag 71.5 ER', acetaminophen prn,
atenolol 25', oxycodone prn, pravastatin 40', senna 8.6'
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Senna 1 TAB PO BID
4. Warfarin 10 mg PO 4X/WEEK (___)
5. Klor-Con *NF* (potassium chloride) 20 mEq Oral daily
6. Maxzide-25mg *NF* (triamterene-hydrochlorothiazid) 37.5-25 mg
Oral daily
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Small Bowel Obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the Colorectal Surgery Service with signs
and symptoms of a bowel obstruction. This was monitored
conservatively and your symptoms resolved. Your ostomy is
functioning and you have tolerated a regular diet, you may
return home. Please monitor your bowel function closely. Please
continue to take an over the counter stool softener such as
Colace and Senna. If you have any of the following symptoms
please call the office for advice or go to the emergency room if
severe: increasing abdominal distension, increasing abdominal
pain, nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or constipation. You have a new
colostomy. It is important to monitor the output from this
stoma. It is expected that the stool from this ostomy will be
solid and formed like regular stool. You should have ___ bowel
movements daily. If you notice that you have not had any stool
from your stoma in ___ days, please call the office. Please
watch the appearance of the stoma, it should be beefy red/pink,
if you notice that the stoma is turning darker blue or purple,
or dark red please call the office for advice. The stoma
(intestine that protrudes outside of your abdomen) should be
beefy red or pink, it may ooze small amounts of blood at times
when touched and this should subside with time. The skin around
the ostomy site should be kept clean and intact. Monitor the
skin around the stoma for bulging or signs of infection listed
above. Please care for the ostomy as you have been instructed by
the wound/ostomy nurses.
The flap from your previous surgery with Dr. ___ Dr.
___ is looking OK, however, you have developed a pressure
ulce near the flap on your buttock and on the incision line.
This has been seen by the plastic surgeon and she is ok with you
using the Mepiplex Sacral dressing over the area. This should
stay in place for 3 days and then be changed to protect the
area. Please be very careful when removing the adhesive border
of the dressing, do not rip it off quickly. Please turn side to
side in bed frequently and avoid sitting directly on this area.
Monitor the wound for signs of infection including: increasing
redness of the incision lines, white/green/yellow/malodorous
drainage, increased pain at the incision, increased warmth of
the skin at the incision, or swelling of the area. Please call
the office if you develop any of these symptoms or a fever. You
may go to the emergency room if your symptoms are severe. You
may shower; pat the aareadry with a towel, do not rub. Please no
baths or swimming until told otherwise by Dr. ___. You will
have a visiting nurse to monitor the wound once a week and you
should see Dr. ___ a wound check in 2 weeks. Please
call her office or Dr. ___ with any issues related to the
flap or wounds.
Please continue to take your Coumadin as you were at home. It is
important that you have an INR check tomorrow, ___.
You take Coumadin M, W, F 12.5mg and T, TH, ___ 10mg.
Please have this done at the ___ Cancer ___,
___. You can have it checked between 10am-12am or
2pm-4pm there.
Please call Dr. ___ office to reschedule your follow-up
appointment that was arranged for you today, your day of
discharge. We took out the staples prior to you leaving which
Dr. ___ about. Please call her office to make this
appointment for within a week of discharge. Continue to hold
prevastatin.
Followup Instructions:
___
|
10150299-DS-17 | 10,150,299 | 25,312,997 | DS | 17 | 2139-05-03 00:00:00 | 2139-05-03 18:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
seasonal / Hydromorphone
Attending: ___.
Chief Complaint:
Dizziness, Nausea, Abnormal MRI finding
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ woman with a history of multiple previous
right wrist surgeries who presents to the ED as a referral from
her PCP. Her and her partner provide a good history. Two days
prior, in the setting of otherwise good health, she woke up and
felt quite lightheaded and nauseous. She was able to get dressed
and get to work, but over the next ___ hours started to develop
a
sensation of the world moving up and down. It was strictly not a
spinning sensation, but there was a clear sensation of motion.
She was not pulsed to one side or the other. It would get worse
with eye movements, and certainly worse with quick movements of
her head. It would improve somewhat with her lying down in bed
and keeping her head still, but not completely. She went to a
local ED and was diagnosed with "BPV" and given meclizine
prescription. She took two tablets that night, and only felt
sleepy but did not improve the above symptomatology.
The next morning, she continued to be symptomatic. She was
somehow able to carry out her daily activities, but the symptoms
persisted until the next day. She finally got a chance to visit
her PCP this afternoon, and the PCP felt that her symptoms were
not consistent with a peripheral vertigo, and referred her to
our
ED for a possible MRI to rule out a central cause for vertigo.
Ms. ___ describes some other symptoms that are not
characteristic of peripheral vertigo, including palinopsia (she
describes a trail of peristent images when objects move
laterally
in her visual field). She also reports a very significant
pressure like sensation in the occiput and retro-orbital
regions.
She has had significant gait difficulties. She describes a
sensation of loss of peripheral vision, and a very vaguely
described blurring of her vision.
Review of systems is negative for double vision, dysphagia,
asymmetric weakness or new numbness (she has some numbness
around
her left knee and right wrist following surgeries to those
regions). She has had diminished PO intake and has been
constipated.
Past Medical History:
1. snowboard injury ___ -> chronic back pain
2. frequent headaches
3. asthma
4. s/p "multiple" sports-related concussions
5. depression and anxiety - has had multiple psych admissions
for SI/self injurious behavior/thoughts
6. asthma - well controlled, no hospitalizations or intubations
Social History:
___
Family History:
History of stroke in paternal grandmother. ___ grandmother
and uncle who committed suicide, extensive history of depression
and alcohol abuse in her family.
Physical Exam:
========================
ADMISSION PHYSICAL EXAM
========================
Gen: Female appears stated age, with multiple tattoes and
piercing. Lying visibly uncomfortable but easily engaged in
conversation.
HEENT: PERRLA, MMM
Neck: Normal neck flexion and extension
Lungs: CTAB, no wheezes or crackles
CV: RRR, normal s1 and s2. No murmurs/gallops
Abd: Soft, NT, ND. Normobowel sounds present.
Ext: WWP, 2+ pulses b/l, no edema.
Neurological examination:
-Mental Status
Patient is awake alert and oriented x3. She was able to relate
the history in full sentences without difficulty. Good
attention, able to spell WORLD backwards and name ___ backwards
without difficulty. Good knowledge of current events. Language
is fluent. Normal prosody. NO paraphasic errors. Speech non
dysarthric.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1mm and brisk, VFF to confrontation.
III, IV, VI: Normal eye movements without visible nystagmus.
Normal saccades.
V: Facial sensation intact to light touch/pinprick.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger rub bilaterally
IX, X: Palate elevates symmetrically.
XI: Good trapezii and SCM strength
XII: Tongue protrudes in midline.
-Motor: Normal bulk throughout. No pronator drift. No
adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
___ ___
L 5 5 5 5 5 ___ 5 4+ 4+ 4+ 5
5
R 5 4- 4- 4- 5 ___ 5 5 5 5 5
5
-Sensory: Decreases sensation to pinprick along LLE from below
the left knee to the ___. Intact sensation along RLE.
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 2+ 2+ 0
R 2+ 2+ 2+ 2+ 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, slowed finger tapping/RAM
bilaterally.
-Gait: Normal tandem gait with some noticeable instability.
=======================
DISCHARGE PHYSICAL EXAM
=======================
Gen: NAD but visibly uncomfortable
HEENT: PERRLA, MMM
Neck: Normal neck flexion and extension. Pain on palpation
Lungs: CTAB, no wheezes or crackles
CV: RRR, normal s1 and s2. No murmurs/gallops
Abd: Soft, NT, ND. Normobowel sounds present.
Ext: WWP, 2+ pulses b/l, no edema.
Neurological examination:
-Mental Status: patient is awake and alert and oriented x3.
Language is fluent and coherent. Normal prosody. No paraphasic
errors. Speech non dysarthric.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1mm and brisk, VFF to confrontation.
III, IV, VI: Normal eye movements without visible nystagmus.
Normal saccades.
V: Facial sensation intact to light touch/pinprick.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger rub bilaterally
IX, X: Palate elevates symmetrically.
XI: Good trapezii and SCM strength
XII: Tongue protrudes in midline.
-Motor: Normal bulk throughout. No pronator drift. No
adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
___ ___
L 5 5 5 5 5 ___ 5 4+ 4+ 4+ 5
5
R 5 5 5 4- 5 ___ 5 5 5 5 5
5
-Sensory: Decreases sensation to pinprick along LLE from below
the left knee to the ___. Intact sensation along RLE.
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 2+ 2+ 0
R 2+ 2+ 2+ 2+ 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, slowed finger tapping/RAM
bilaterally.
-Gait: Normal tandem gait with some noticeable instability.
Pertinent Results:
=======================
LABORATORY STUDIES
=======================
___ 04:40PM GLUCOSE-94 UREA N-11 CREAT-0.6 SODIUM-137
POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-26 ANION GAP-7*
___ 07:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 06:10PM URINE UCG-NEG
___ 06:10PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-POS mthdone-NEG
___ 06:10PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 06:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 03:35PM GLUCOSE-114* UREA N-14 CREAT-0.7 SODIUM-138
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-28 ANION GAP-11
___ 03:35PM estGFR-Using this
___ 03:35PM CALCIUM-9.2 PHOSPHATE-2.6* MAGNESIUM-2.0
___ 03:35PM WBC-7.5 RBC-4.57 HGB-13.5 HCT-41.4 MCV-91
MCH-29.6 MCHC-32.7 RDW-12.9
___ 03:35PM NEUTS-69.4 ___ MONOS-4.9 EOS-1.2
BASOS-0.6
___ 03:35PM PLT COUNT-354
___ 03:35PM ___ PTT-26.3 ___
========================
IMAGING
========================
(___) MRV & MRA Brain w/o Contrast:
1. A 3-mm outpouching off the distal cervical left ICA, with
adjacent intraluminal filling defect, representing a
short-segmental dissection with intimal flap and/or
pseudoaneurysm, of uncertain chronicity. No distal occlusion.
Recommend dedicated MRA neck with axial T1 fat-sat (dissection
protocol) to further assess the dissection/pseudoaneurysm.
2. No intracranial aneurysm, vascular malformation or distal
occlusion. No acute infarct or hemorrhage. No dural sinus
venous thrombosis.
(___) MRA NECK: Neuroradiology fellow prelim read: Left
cervical ICA pseudoaneurysm unchanged from MRA head done one day
prior. No evidence of intramural hematoma on T1 fat-sat images.
Brief Hospital Course:
___ y/o F with hx of ADHD and recurrent headaches presenting with
progressive vertigo, nausea and headache in the setting of MRI
findings notable for L ICA pseudoaneurysm.
Neuro:
Patient underwent neck MRI and MRA w/ fat saturation consistent
with left ICA pseudoaneurysm. She was started on aspirin 325mg
daily and her adderall was held during admission. Patient had
persistent nausea, vertigo, headache and photophobia likely in
the setting of migraine which was managed with
Oxycodone-Acetaminophen. Given no evidence of infarct or
thrombosis on MRI and stable pseudoaneurysm without evidence of
expansion, patient was discharged with plan for daily aspirin
for 2 months until her follow-up with the neurology clinic,
where further imaging may be re-evaluated.
CV:
Patient's blood pressure remained stable during current
admission, ranging between 102/49-120/50 and monitored by
telemetry. Her long history of smoking was identified as a risk
factor and patient was counseled on the benefits of smoking
cessation.
ID:
Patient was afebrile without leukocytosis and negative UA.
Although there was low suspicion for an infectious etiology, an
infectious work-up for possible osteomyelitis was done, with a
normal ESR and pending CRP.
FEN: Patient was maintained on cardiac healthy diet.
PPX:Patient received sq heparin and pneumoboots for prophylaxis.
Medications on Admission:
-Adderral 20mg TID
-Ativan ___ mg QHS
Discharge Medications:
1. Lorazepam ___ mg PO HS sleep
2. Aspirin 325 mg PO DAILY
3. Adderall *NF* (amphetamine-dextroamphetamine) 20 mg Oral TID
Discharge Disposition:
Home
Discharge Diagnosis:
Pseudoaneurysm of the left internal carotid artery
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for dizziness, headache, and an imaging
finding of possible left carotid dissection. A second focused
imaging study of the arteries showed that you had a
pseudoaneurysm of the left internal carotid artery. This is a
blood clot that formed in a damaged wall of the artery. It puts
you at risk of forming blood clots that could travel to the
brain and cause a stroke. Because of this, we started you on
aspirin therapy to reduce the risk of forming blood clots. We
also counseled you to stop smoking, as smoking greatly increases
your risk of stroke.
Please call patient relations between 830am-400pm tomorrow at
___ to speak with ___ about your hospitalization and
the cost of your return to the emergency department.
It was a pleasure taking care of you at ___.
Followup Instructions:
___
|
10150423-DS-2 | 10,150,423 | 24,100,930 | DS | 2 | 2138-02-15 00:00:00 | 2138-02-15 18:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest Pain, NSTEMI
Major Surgical or Invasive Procedure:
Coronary angiography s/p DES to LAD
Impella Device
Central venous line insertion
History of Present Illness:
___ with history of HTN, HL presents with chest pain, belching
sensation since this afternoon. Referred from outside hospital
for positive troponin, concern for NSTEMI. Patient received full
dose aspirin and was started on a heparin drip at the outside
hospital. Also underwent a chest x-ray which was normal.
In the ED initial vitals were: T 98.1, HR 82, BP 126/77, RR 16,
O2 97% RA
EKG: Rate 69, sinus rhythm, L axis deviation, 1mm ST elevation
in I
Labs/studies notable for: CBC, BMP, Troponin 0.64
Patient was given: Heparin gtt, SL nitro x1, 1L NS
Vitals on transfer: 97.8, 65, BP 107/51, RR 14, O2 97% RA
On the floor history obtained with assistance of his wife,
patient refused phone ___ interpreter. Patient reports he
developed belching yesterday afternoon when he became anxious.
He frequently has episodes of bleching, but yesterday he had
associated L sided chest pressure ___ in severity. Chest
pressure was present in ED, improved slightly with SL nitro. Now
___ in severity. Has no other complaints. Denies associated
syncope, PND, SOB with exertion, abdominal pain, nausea,
dysuria, diarrhea.
REVIEW OF SYSTEMS:
Cardiac review of systems is negative for dyspnea on exertion,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope, or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes (diet-managed)
- Hypertension
2. CARDIAC HISTORY
- None
3. OTHER PAST MEDICAL HISTORY
- Possible Polymyalgia rhematica
- DJD of hands and narrowing of MCP joints
- Spinal stenosis, lumbar
- Osteoporosis
- Colonic adenoma
- Irregular heart rhythm- EKG ___ with bigemeny and premature
atrial beats
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathy,
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
================================
VS: T 98.9, HR 68, BP 89/64, O2 98%
GENERAL: Well developed, well nourished in NAD. Intubated,
Sedated.
HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI.
NECK: Supple. Unable to assess JVP
CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or
gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No adventitious breath
sounds.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAMINATION:
=================================
98.4 PO 101/65 91 18 96 Ra
GENERAL: Well appearing man sitting up in bed.
HEENT: Pupils equal and reactive. No scleral icterus or
injection. Moist mucous membranes.
NECK: Supple with JVP visible at the base of the neck while
lying flat.
CARDIAC: S1/S2 regular with no murmurs, rubs, heaves or S3/S4.
LUNGS: Lungs clear to auscultation bilaterally with no use of
accessory muscles or other evidence of respiratory distress.
ABDOMEN: Soft, NTND. No HSM or tenderness.
Groin: Bruising in the R groin with dressing clean, dry and
intact. Femoral pulse palpable. No bruits auscultated.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION LABS:
===============
___ 02:10AM BLOOD WBC-8.4 RBC-4.69 Hgb-14.5 Hct-41.8 MCV-89
MCH-30.9 MCHC-34.7 RDW-13.2 RDWSD-43.1 Plt ___
___ 02:10AM BLOOD Neuts-73.5* Lymphs-18.9* Monos-6.8
Eos-0.2* Baso-0.2 Im ___ AbsNeut-6.14* AbsLymp-1.58
AbsMono-0.57 AbsEos-0.02* AbsBaso-0.02
___ 05:56AM BLOOD ___ PTT-46.7* ___
___ 02:10AM BLOOD Glucose-187* UreaN-17 Creat-0.8 Na-141
K-4.4 Cl-103 HCO3-25 AnGap-13
___ 02:10AM BLOOD CK(CPK)-891*
___ 02:10AM BLOOD CK-MB-137* MB Indx-15.4*
___ 02:10AM BLOOD Calcium-9.3 Phos-2.8 Mg-1.8
___ 04:20PM BLOOD Glucose-205* Lactate-1.1 Na-136 K-3.2*
Cl-105
___ 04:20PM BLOOD O2 Sat-99
___ 10:11PM BLOOD freeCa-1.15
MICRO:
======
no positive results
DISCHARGE LABS:
===============
___ 06:35AM BLOOD WBC-8.4 RBC-4.06* Hgb-12.5* Hct-36.5*
MCV-90 MCH-30.8 MCHC-34.2 RDW-13.4 RDWSD-44.4 Plt ___
___ 06:35AM BLOOD Glucose-205* UreaN-35* Creat-1.0 Na-136
K-4.3 Cl-97 HCO3-25 AnGap-14
___ 06:35AM BLOOD ALT-41* AST-36 LD(LDH)-551* AlkPhos-56
TotBili-1.4
___ 06:35AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.0
IMAGING:
==============
CXR ___:
Lungs are low volume with bibasilar atelectasis. Heart size is
normal. There is no pleural effusion. No pneumothorax is seen.
There is no evidence of pneumonia.
___ Cardiovascular Cath Physician ___
1. Three vessel CAD in this left dominant coronary system with
evidence of intraluminal thorombus in the left main that
embolized down the LAD
2. VF arrest prior to attempted PCI
3. Thrombectomy of the left main and Successful PCI of the
Proximal LAD with a 3.0 DES posted with a 4.0 balloon with
hemodynamic support
4. Impella CP catheter placed for hemodynamic support post
cardiac arrest at conclusion of PCI, this was exchanged out for
an IABP for enhanced circulatory support
___ Cardiovascular ECHO
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. LV systolic function appears
moderately-to-severely depressed (LVEF = 30%) secondary to
extensive inferior, posterior, and lateral wall hypokinesis with
focal inferior posterior akinesis; apex is also hypokinetic. The
right ventricular free wall thickness is normal. The right
ventricular cavity is mildly dilated with focal hypokinesis of
the apical free wall. The mitral valve leaflets are mildly
thickened. Moderate to severe (3+) mitral regurgitation is seen.
[Due to acoustic shadowing from the Impella catheter, the
severity of mitral regurgitation may be significantly
UNDERestimated.] There is no pericardial effusion.
Impella inflow port 2.9 cm from aortic valve.
___ Imaging CHEST (PORTABLE AP)
In comparison with the study of ___, the Impella has been
removed. The monitoring and support devices are essentially
unchanged. Cardiomediastinal silhouette is stable. Mild
bibasilar opacifications most likely represent atelectasis. No
definite vascular congestion or acute focal pneumonia.
Brief Hospital Course:
=================
SUMMARY STATEMENT
=================
Mr. ___ is a ___ year-old male with history of HTN, HLD who
presented to OSH with chest pain and belching sensation on
___, initially transferred to ___ for NSTEMI. His course
was complicated by VT arrest during coronary angiography,
subsequent intubation, and shocks x2 necessitating Impella
support. Ultimately, he was able to be weaned from aggressive
cardiac support, was subsequently extubated, and continued to
improve from a cardiovascular standpoint to the time of
discharge.
#CORONARIES: LHC ___:
-Dominance: Left
- Left Main Coronary Artery: The LMCA had a filling defect noted
on diagostic angiography
- Left Anterior Descending: The LAD is has a proximal tubular
70%stenosis The ___ Diagonal is a medium caliber branch, non
obstructive.
- Circumflex: The Circumflex has a proximal 60-70% stenosis, the
mid LCX is occluded (100%) and the distal vessel fills via
bridging ipsilateral collaterals and fills the L-PDA.
- Right Coronary Artery: The RCA is non dominant and has a 99%
stenosis, proximal to the RV marginal branch.
#PUMP: 35-40% LVEF
#RHYTHM: NSR
=============
ACTIVE ISSUES
=============
# Non-ST Elevation Myocardial infarction
# Acute LAD Occlusion
# Cardiogenic Shock, s/p Impella device support
# s/p VT Arrest
# s/p intubation for respiratory failure
Presented with chest pain & belching, with elevated troponin c/w
NSTEMI. Transferred to ___ for further evaluation and care. He
was initially treated medically and anticoagulated. His pain was
responsive to nitroglycerine. He proceeded to coronary
catheterization, which was complicated by thrombus formation
during the case, and the patient subsequently became
hypotensive. He required Impella device support as well as
vasopressor support. He was intubated for airway protection
given AMS iso shock. Ultimately, catheterization revealed L
Main, then RCA, PDA, ___ LAD lesions. LAD lesion was stented,
and he was cared for in intensive care until he was successfully
extubated and weaned vasopressor support. His medication regimen
was optimized prior to discharge, and he will leave on DAPT,
lisinopril and metoprolol.
# HFrEF
TTE following catheterization showed EF of 35-45% with
___ wall motion abnormalities. He was diuresed while
in the ICU, but while on the floor was maintaining euvolemia
despite no diuretic regimen. He will be discharged to close
follow-up with cardiology, and will need a repeat TTE to
evaluate his ejection fraction in 1 month, and will be
discharged on lisinopril and metoprolol.
___: Developed during active diuresis in the ICU. Resolved with
cessation of diuretics.
==============
CHRONIC ISSUES
==============
# HLD
Previously on simvastatin 20mg, recently discontinued by PCP.
Atorvastatin 80mg started for CAD.
# DM
HbA1c 6.8 in ___. Now off home metformin and Humalog.
Maintained on SSI this admission.
# Possible PMR
Currently asymptomatic, not on home meds.
===================
TRANSITIONAL ISSUES
===================
- New Meds: Aspirin 81mg daily; Atorvastatin 80mg every night;
Lisinopril 2.5mg daily; Metoprolol Succinate 12.5mg daily;
Ticagrelor 90mg BID
- Stopped/Held Meds: None (was not previously on any meds)
- Changed Meds: None (was not previously on any meds)
- Post-Discharge Follow-up Labs Needed: Routine labs at next
visit
- Incidental Findings: None
- Discharge weight: ___ 70.0kg (154.32 pounds)
[ ] Continue to assess volume status. He was diuresed in CCU
following his complicated catheterization and VF arrest, but was
found to be euvolemic thereafter and was not discharged on a
diuretic.
[ ] Patient should received follow-up TTE in ___ months to
assess for recovery in LV function
[ ] Patient should have close monitoring of blood pressures, and
he had new hypotension after his VF arrest and was started on
beta-blocker and lisinopril this admission for management of his
NSTMEI and HFrEF
[ ] Confirmed with patient that co-pay for ticagrelor was
acceptable, please ensure he continues to take this medication
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth nightly Disp #*90
Tablet Refills:*0
3. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Metoprolol Succinate XL 12.5 mg PO DAILY
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
5. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis
RX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
=================
PRIMARY DIAGNOSIS
=================
Acute coronary syndrome
VT arrest
acute on chronic HFrEF
Cardiogenic shock
===================
SECONDARY DIAGNOSES
===================
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you while you were admitted to ___
___.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were having
chest pain and we did tests that showed you were having a heart
attack.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We put stents in your heart to treat the heart attack.
- While you were having your stents put in, you had a sudden
blockage of the heart that caused your heart to stop beating
well. We shocked your heart and put in a temporary device to
help your heart pump. You went to an intensive care unit after
this. Thankfully we were able to remove the device and you
recovered quickly.
WHAT SHOULD YOU DO WHEN YOU GO HOME?
Sincerely,
Your ___ Cardiology Team
Followup Instructions:
___
|
10150423-DS-3 | 10,150,423 | 29,203,506 | DS | 3 | 2138-10-04 00:00:00 | 2138-10-06 06:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with CAD s/p NSTEMI ___, DES
to LAD (c/b ICU stay with Impella, vaspopressors, and
intubation), HFrEF (EF 45% ___, HTN, DM2, who presents for
fever and vomiting for 2 days.
He was in his usual state of health until ___ when he had
NBNB emesis x5, poor PO tolerance, and low grade temperature of
100.9. He presented to an outpatient provider who suspected
symptoms were likely viral. The patient took acetaminophen but
had worsening fever to 101s the following day in addition to new
rigors, chills, diaphoresis, diarrhea, and productive cough with
yellow sputum. He had minimal PO intake and reported continued
vomiting, though less frequent. He denied chest pain, SOB,
palpitations, headache, lightheadedness, dizziness, vision
changes, abdominal pain, or urinary symptoms.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes (diet-managed)
- Hypertension
2. CARDIAC HISTORY
- None
3. OTHER PAST MEDICAL HISTORY
- Possible Polymyalgia rhematica
- DJD of hands and narrowing of MCP joints
- Spinal stenosis, lumbar
- Osteoporosis
- Colonic adenoma
- Irregular heart rhythm- EKG ___ with bigemeny and premature
atrial beats
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathy,
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: T 97.8, 123/61, HR 83, RR 18, 97% RA
GENERAL: well-appearing, NAD, intermittent cough
HEENT: NC/AT, EOMI, mucous membranes dry
NECK: supple, no JVD appreciated
CARDIAC: rrr, normal s1 s2, no murmurs/rubs/gallops
LUNGS: decreased breath sounds at right base with crackles and
egophony, no increased WOB, no wheezes
ABDOMEN: normoactive bowel sounds, soft, nontender,
nondistended, no masses appreciated
EXTREMITIES: wwp, no ___ edema
NEUROLOGIC: A&Ox3, gross motor and sensation intact
SKIN: wwp, diaphoretic, slightly flushed, no rashes appreciated
DISCHARGE PHYSICAL EXAM:
VITAL SIGNS: ___ 0749 Temp: 98.4 PO BP: 113/64 HR: 90 RR:
20 O2 sat: 91% O2 delivery: RA FSBG: 186
GENERAL: well-appearing, NAD, intermittent cough with blood
tinge
HEENT: NC/AT, EOMI, mucous membranes dry
NECK: supple, no JVD appreciated
CARDIAC: rrr, normal s1 s2, no murmurs/rubs/gallops
LUNGS: egophony sounds heard during expiration, no increased
WOB, no wheezes
ABDOMEN: normoactive bowel sounds, soft, nontender, nondistended
EXTREMITIES: wwp, no ___ edema
NEUROLOGIC: A&Ox3, gross motor and sensation intact
SKIN: wwp, diaphoretic, no rashes appreciated
Pertinent Results:
ADMISSION LABS:
___ 03:52AM BLOOD WBC-8.3 RBC-4.99 Hgb-15.2 Hct-44.2 MCV-89
MCH-30.5 MCHC-34.4 RDW-14.1 RDWSD-45.9 Plt ___
___ 03:52AM BLOOD Neuts-87.7* Lymphs-4.6* Monos-7.2
Eos-0.0* Baso-0.1 Im ___ AbsNeut-7.32* AbsLymp-0.38*
AbsMono-0.60 AbsEos-0.00* AbsBaso-0.01
___ 03:52AM BLOOD Glucose-198* UreaN-36* Creat-1.2 Na-129*
K-4.2 Cl-92* HCO3-22 AnGap-15
___ 03:52AM BLOOD ALT-156* AST-143* AlkPhos-56 TotBili-1.9*
___ 03:52AM BLOOD Albumin-3.5
___ 10:20AM BLOOD Calcium-7.9* Phos-4.1 Mg-1.9
MICRO:
___ Blood cultures: no growth to date
___ Urine legionella: negative
___ Urine culture: no growth
IMAGING:
___ Liver US:
1. Status post cholecystectomy without evidence of biliary
ductal dilatation.
2. Mild splenomegaly, measuring up to 13.1 cm.
3. Probable hemangioma in the right lobe of the liver.
___ Chest XRAY:
New focal consolidation within the right lower lobe is likely
compatible with right lower lobe pneumonia. Follow-up to
complete resolution after course of antibiotics is ___ weeks is
recommended
DISCHARGE LABS:
___ 06:15AM BLOOD WBC-5.7 RBC-4.82 Hgb-14.8 Hct-43.7 MCV-91
MCH-30.7 MCHC-33.9 RDW-14.4 RDWSD-48.1* Plt ___
___ 06:15AM BLOOD Glucose-121* UreaN-24* Creat-0.9 Na-134*
K-4.1 Cl-98 HCO3-25 AnGap-11
___ 06:15AM BLOOD ALT-239* AST-218* AlkPhos-52 TotBili-1.1
___ 06:15AM BLOOD Calcium-8.1* Phos-2.7 Mg-2.1
Brief Hospital Course:
Mr. ___ is a ___ year old man with CAD s/p NSTEMI ___, DES
to LAD (c/b ICU stay with Impella, vaspopressors, and
intubation), HFrEF (EF 45% ___, HTN, DM2, who presented for
fever and vomiting for 2 days and found to have right lower lobe
consolidation on CXR concerning for community-acquired
pneumonia.
ACUTE ISSUES:
=============
# Community-acquired pneumonia:
Patient with fever and new productive cough and trace
hemoptysis. Afebrile in ED. Most consistent with
community-acquired pneumonia. Urine legionella negative, sputum
culture unrevealing. He received ceftriaxone 1g IV q24hrs and
Azithromycin 250mg PO q24hrs on ___ and ___. Has been afebrile
on ___. Will continue treatment with Cefpedoxime 400mg q12 and
Azithromycin 250 q24 for total five day treatment (Last day:
___.
# Vomiting and diarrhea:
Reported nonbilious non bloody emesis five times on ___, poor
PO tolerance, and low grade temperature to 100.9 at home. He
received 1L NS in ED. Emesis improved on ___ but had few
episodes of diarrhea. Symptoms suggestive of viral
gastroenteritis. Encouraged PO intake during the hospitalization
and his symptoms improved.
# Hyponatremia
Na 129 on presentation (132 in ___. Likely hypovolemic in
the setting of poor PO intake and vomiting. s/p 1L NS in ED with
improvement to 133. Stable in ___ on discharge.
# Transaminitis
Liver enzymes elevated (ALT 239, AST 218) with normal alk phos
and total bili. Likely drug-induced cholestasis in the setting
of ceftriaxone. RUQ US without any concerning features for
infection. Outpatient follow-up within one week.
# Acute Kidney Injury
Presented with creatinine 1.2 (baseline 0.8-1). Likely iso of
vomiting and poor PO intake prior to admission. Encouraged PO
intake and it resolved by discharge.
# Frequent premature ventricular contractions
Patient presented with frequent premature ventricular
contractions on EKG though asymptomatic and without
palpitations. Also with left axis deviation, stable from prior
admission. Monitored on tele during this hospitalization.
CHRONIC ISSUES
==============
# Coronary artery disease
s/p NSTEMI in ___ (course c/b clot formation during
catheterization, requiring ICU stay with Impella device,
vasopressors, and intubation) with DES to LAD. Continued with
aspirin, tacagrelor, atorvastatin.
# Chronic systolic heart failure
TTE in ___ with EF 45% (improved compared to EF 30% s/p
NSTEMI in ___. Compensated during this hospitalization. Held
home lisinopril and metoprolol given hypotension and poor PO
intake.
# Hyperlipidemia
Continued atorvastatin.
# Diabetes Mellitus Type II
HbA1c 6.7 in ___. Diet-controlled and on glimepiride at home.
Held glimepiride while inpatient and treated with insulin
sliding scale.
TRANSITIONAL ISSUES:
====================
[ ] Outpatient follow-up within one week for elevated LFTs and
hyponatremia re-evaluation
[ ] Can restart home lisinopril and metoprolol if he becomes
hypertensive. Systolic BPs on day of discharge 100-110s
[ ] if develops palpitations, consider monitor for ectopy
[ ] please continue cefpodoxime and azithromycin until ___
CORE MEASURES
=============
# CODE: full
# CONTACT: ___ (wife): ___ / ___ (son):
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Lisinopril 2.5 mg PO DAILY
4. Metoprolol Succinate XL 12.5 mg PO DAILY
5. TiCAGRELOR 90 mg PO BID
6. Sertraline 37.5 mg PO DAILY
7. glimepiride 1 mg oral DAILY
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 2 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
2. Cefpodoxime Proxetil 400 mg PO Q12H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp #*8
Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. glimepiride 1 mg oral DAILY
6. Sertraline 37.5 mg PO DAILY
7. TiCAGRELOR 90 mg PO BID
8. HELD- Lisinopril 2.5 mg PO DAILY This medication was held.
Do not restart Lisinopril until seen by primary care provider
9. HELD- Metoprolol Succinate XL 12.5 mg PO DAILY This
medication was held. Do not restart Metoprolol Succinate XL
until seen by primary care provider
___:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
COMMUNITY-ACQUIRED PNEUMONIA
SECONDARY DIAGNOSES:
HYPONATREMIA
CORONARY ARTERY DISEASE
CHRONIC DIASTOLIC HEART FAILURE
HYPERLIPIDEMIA
TYPE II DIABETES MELLITUS
ACUTE KIDNEY INJURY
HYPERTENSION
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
WHAT BROUGHT YOU TO THE HOSPITAL?
You came in with fever and several episodes of vomiting.
WHAT WAS DONE IN THE HOSPITAL?
You were found to have a pneumonia. You were treated with
antibiotics. We held your blood pressure medications, as your
blood pressure was on the lower range while in the hospital.
Your liver enzymes were found to be elevated.
WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL?
-You should continue your antibiotics as prescribed.
-You should follow-up with your primary care provider.
-You should get your liver enzymes checked within one week.
-Weigh yourself every morning.
-Call a physician if your weight goes up more than 3 lbs in one
day or more than 5 lbs in one week.
We wish you the very best. It was a pleasure taking care of you
in the hospital.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10150465-DS-15 | 10,150,465 | 23,902,861 | DS | 15 | 2152-06-23 00:00:00 | 2152-07-01 17:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/CKD, recent pancreatitis presents w/epigastric pain and
vomiting. Pain began yesterday. Radiates to back. Has had 4
episodes of NBNB emesis. Has been constipated for 1 week, which
is a chronic problem. Reports that since discharge for prior
pancreatitis has had ___ more episodes of pain which were less
intense and lasted only a few hours. Difficult to obtain full
history as pt falling asleep repeatedly during interview, but
she states that her diet is poor, that she eats "junk". When
asked to be more specific says she does not eat "solid" foods
just whatever is nearby when she is hungry. When asked to
recount what she ate the day prior to her pain started she
stated "cheesecake" unable to give more details due to
somnolence.
Of note pt was admitted to ___ ___ with acute
pancreatitis lipase>1000 on admission. This was her first
episode of pancreatitis. She was managed conservatively and was
discharged without pain medication, tolerating a low fat diet.
Work up during that admission included RUQ US which did not show
cholelithiasis. CT abd confirmed acute pancreatitis without any
other pathology. ___ 347. ETOH 6. Normal LFTs. Pancreatitis was
attributed to ETOH by MDs, but pt denies this. Was seen by PCP
in follow up last ___ and MRI completed ___ found enlargement
of pancreatic head read a mass v. pseudocyst. The study was
limited by lack of contrast due to renal function.
No hx of gallstones, etoh. No recent GI or respiratory illness.
Pt is on several medications which are associated with
pancreatitis: simvastatin was started ___, estrogen since
___, ranitidine since ___ without any recent dosage changes.
No recent abdominal trauma.
In ED lipase 2984. Pt given morphine and 1Lns.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
Stage IV CKD
Pancreatitis
Anxiety
Hypothyroid
GERD
Social History:
___
Family History:
Sister w/DM
Mother dx pancreatic ___ age ___
Physical Exam:
ADMISSION
Vitals: T:98 BP:146/68 P:79 R:16 O2:95%ra
PAIN: 7
General: nad
EYES: anicteric
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, distended, tender
epigastrium
Ext: no e/c/c
Skin: no rash
Neuro: somnolent, speech fluent, moving all extremities
DISCHARGE
VS: 98.7 130/70 77 18 100%RA
Gen: sitting up at edge of bed eating a sandwich, comfortable
Eyes - EOMI
ENT - poor dentition, OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft nontender, normoactive bowel sounds, no masses
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3, moving all extremities
Psych - appropriate
Pertinent Results:
OSH non-con MRI Abd ___ IMPRESSION:
1. Enlargedment of the head of the pancreas which may be due to
focal pancreatitis or pancreatic mass.
2. Rather significant hepatic statosis.
3. Doduenal diverticulum v. pancreatic pseudocyst. CT scan with
oral contrast may add further information
4. Pancreas divisum.
RUQ U/S ___
1. Limited pancreas view. Within limitations, no pancreatic
pseudocyst or
pancreatic ductal dilatation.
2. Echogenic liver consistent with steatosis. Other forms of
liver disease and more advanced liver disease cannot be excluded
on this study.
Brief Hospital Course:
This is a ___ year old female with past medical history of CKD
stage IV, hypothyroidism and prior episode of pancreatitis, with
outpatient MRI showing possible pancreatic head mass vs cyst,
admitted here with epigatric pain found to have acute
pancreatitis, unclear etiology, clinically improving without
clear etiology, declining additional evaluation and workup,
discharged home to follow-up with PCP and advanced endoscopy.
# Acute Pancreatitis - patient with recent diagnosis of possible
pancreatic mass on MRI (was poor quality due to inability to
give contrast ___ CKD) admitted with nausea and abdominal pain,
similar in character to prior episode of pancreatitis, found to
have lipase of 2984; patient was treated with conservative
management, IV fluids, bowel rest, prn symptom control. RUQ
ultrasound did not demonstrate pseudocyst or pancreatic ductal
dilatation. Symptoms improved, and although patient was
recommended for additional inpatient evaluation by advanced
endoscopy / ERCP team, patient declined and reported she would
keep outpatient appointment with Dr. ___. We discussed
risks of discharge without workup including pancreatitis
recurrence, which patient was able to verbalize understanding
of. Workup otherwise notable for normal triglycerides. Emailed
PCP and Dr. ___ to inform, discharged patient home with
previously scheduled follow-up.
for outpatient follow-up
# Constipation - patient with history of constipation, worse
during this admission. In rare cases, constipation can cause
pancreatitis. She responded well to miralax and senna, which
she was sent home with prescriptions for at her request.
# CKD stage IV - in rare cases, calcitriol can cause
pancreatitis; decreased dose given concern for contribution to
pancreatitis during this admission
# Anxiety / Depression - continued home BusPIRone,
amitriptyline, propranolol
# Hypothyroidism - continued home levothyroxine
# GERD - continued home PPI
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amitriptyline 30 mg PO QHS
2. BusPIRone 20 mg PO BID
3. Calcitriol 0.25 mcg PO DAILY
4. Estradiol 1 mg PO DAILY
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Lorazepam 0.5 mg PO Q8H:PRN anxiety
7. Propranolol LA 240 mg PO DAILY
8. Ranitidine 300 mg PO TID
9. Simvastatin 40 mg PO QPM
10. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
Discharge Medications:
1. Amitriptyline 30 mg PO QHS
2. BusPIRone 20 mg PO BID
3. Calcitriol 0.25 mcg PO EVERY OTHER DAY
Please talk to your PCP and your nephrologist about this change.
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Lorazepam 0.5 mg PO Q8H:PRN anxiety
6. Propranolol LA 240 mg PO DAILY
7. Zolpidem Tartrate 5 mg PO QHS
You should try to take the lowest possible dose of this
medication.
8. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*90
Tablet Refills:*0
9. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 by mouth twice daily Disp #*90
Tablet Refills:*0
10. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 packet by mouth
daily Disp #*24 Packet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatitis
Pancreatic mass
Acute Kidney Injury / CKD Stage IV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___:
It was a pleasure caring for you at ___. You were admitted to
the hospital with abdominal pain, nausea, vomiting. You were
diagnosed with pancreatitis. You were treated with IV fluids,
pain medications, and no eating. You underwent testing to look
for the cause of your pancreatitis. An ultrasound of your
abdomen did not show any gallstones. In order to further work-up
your recent abnormal MRI that showed a mass in your pancreas, we
recommended you see a gastroenterologist during this admission,
but you declined and opted to keep you outpatient appointment
scheduled for ___.
Followup Instructions:
___
|
10150465-DS-16 | 10,150,465 | 25,699,609 | DS | 16 | 2152-08-15 00:00:00 | 2152-08-18 22:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Leukocytosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with past episodes of pancreatitis, CKD presenting as
referral after lab worked showed evidence of acute on chronic
kidney disease as well as a leukocytosis. Patient may have had a
fever to 101-102 at one point last week. Reports persistent
abdominal pain, 15 lb weight loss over 2 months, poor PO intake,
fatigue. Pt also reports ongoing dyspnea with exertion for the
past 2 months.
Patient was hospitalized in ___ with acute pancreatitis
with resolved with supportive care. An OSH MRI showed question
of a pancreatic head mass so EUS was recommended but patient
refused further diagnostics and elected to follow up with her
gastroenterologist Dr. ___ as an outpatient. She underwent
EUS on ___ which did not show pancreatic mass. MRCP was
recommended and planned for outpatient study.
In the ED, intitial vitals: 99.2 89 ___ 100%RA. Patient
received 2L NS and nicotine patch. CT abdomen was planned but
patient refused in the ED because she didn't think she could
drink the contrast material.
Labs in the ED revealed..
Lactate 1.7
WBC 19.5
Hgb 10.0
Plts ___ 33 92 AGap=21
3.7 15 2.8
Albumin 2.9
Lipase: 61
Unremarkable urinalysis
ED Course: Blood cultures were drawn and patient was admitted to
the medicine service for further work up of her leukocytosis and
weight loss.
On arrival to the floor, vitals were T 97.5, 137/66, 73, 18,
99%RA
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
Stage IV CKD
Pancreatitis
Anxiety
Hypothyroid
GERD
Social History:
___
Family History:
Sister w/ DM
Mother dx pancreatic ___ age ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Tc 97.5, 137/66, 73, 18, 99%RA
GENERAL: NAD
HEENT: Anicteric sclera, MMM, poor dentition with many missing
teeth
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Diffuse mild tenderness to palpation. Nondistended,
+BS, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
DISCHARGE PHYSICAL EXAM:
VS - Tm 98.3, 112-120/63-70, 65-75, 18, 100%RA
GENERAL: NAD
HEENT: Anicteric sclera, MMM, poor dentition with many missing
teeth
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Diffuse mild tenderness to palpation. Nondistended,
+BS, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
Pertinent Results:
==== ADMISSION LABS ====
___ 02:50PM BLOOD WBC-19.5* RBC-3.25* Hgb-10.0* Hct-30.4*
MCV-94 MCH-30.6 MCHC-32.8 RDW-14.1 Plt ___
___ 02:50PM BLOOD Neuts-81.4* Lymphs-13.5* Monos-4.5
Eos-0.3 Baso-0.3
___ 02:50PM BLOOD Glucose-92 UreaN-33* Creat-2.8* Na-136
K-3.7 Cl-104 HCO3-15* AnGap-21*
___ 06:30AM BLOOD Calcium-9.4 Phos-4.8* Mg-1.6
___ 02:50PM BLOOD Albumin-2.9*
___ 02:50PM BLOOD ALT-17 AST-22 AlkPhos-131* TotBili-0.3
___ 02:50PM BLOOD Lipase-61*
___ 02:50PM BLOOD TSH-0.22*
___ 03:13PM BLOOD Lactate-1.7
==== DISCHARGE LABS ====
___ 06:15AM BLOOD WBC-11.7* RBC-2.96* Hgb-9.1* Hct-28.4*
MCV-96 MCH-30.7 MCHC-32.0 RDW-13.8 Plt ___
___ 06:29AM BLOOD Neuts-73.9* ___ Monos-4.8 Eos-1.5
Baso-0.3
___ 06:15AM BLOOD Glucose-72 UreaN-23* Creat-2.3* Na-140
K-4.4 Cl-111* HCO3-18* AnGap-15
==== MICRO ====
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
==== IMAGING ====
MRCP (___):
INDICATION: ___ year old woman with weight loss / malnutrition,
recent
hospitalization for pancreatitis, report of pancreatic mass on
OSH MRI
presenting with leukocytosis and reports of fevers. // ?
pancreatic
malignancy
TECHNIQUE: T1- and T2-weighted multiplanar images of the
abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: Prohance 11 cc.
COMPARISON: CT abdomen pelvis dating ___. Outside
MRI dating ___. Abdominal ultrasound dating ___.
FINDINGS:
Liver: The liver is normal in size and contour without
morphologic features of
significant fibrosis or cirrhosis. There is diffuse hepatic
steatosis with fat
fraction percentage calculated up to 28%. No focal hepatic
lesion is
appreciated.
Biliary: Intra and extrahepatic bile ducts are normal in caliber
and contour.
There is no cholelithiasis or choledocholithiasis. Cystic change
at the
gallbladder fundus is consistent with focal adenomyomatosis.
Pancreas: The pancreatic parenchyma is mildly atrophied but
maintains
relatively normal parenchymal signal and enhancement. No
peripancreatic
inflammatory change is present. The main pancreatic duct is
notable for
divisum configuration. It is mildly prominent throughout,
measuring up to 3 mm
within the head. A normal smooth contour is, however,
maintained.
Within the pancreatic head just below the ampulla is 1.5 cm
structure which is
partially filled with fluid, but also contains oral contrast,
confirming that
this is a duodenum diverticulum rather than a cystic lesion
within the
pancreas. No additional focal abnormality within the pancreas
is identified.
Spleen: Normal.
Adrenal Glands: Normal
Kidneys: There are innumerable tiny subcentimeter renal cysts
seen
bilaterally, with random distribution throughout the renal
parenchyma. In the
right clinical setting, this appearance is compatible with
lithium
nephropathy.
Gastrointestinal Tract: Aside from the juxta papillary duodenum
diverticulum
no bowel abnormality is identified.
Lymph Nodes: None pathologically enlarged.
Vasculature: Arterial vascular anatomy is conventional. Venous
structures are
widely patent.
Other: There is no ascites or pleural effusion. Mild
degenerative changes
noted at the lower lumbar spine.
IMPRESSION:
1. Moderate hepatic steatosis.
2. No pancreatic mass. There is pancreas divisum and a juxta
papillary
duodenum diverticulum.
3. Innumerable randomly distributed renal microcysts. This
appearance is
typically seen in the setting of lithium nephropathy.
Brief Hospital Course:
___ with past episodes of pancreatitis, CKD presenting with ___,
abdominal pain and ___ lbs weight loss over 2 weeks.
# Pancreas divisum and a juxta papillary duodenum diverticulum:
Read from OSH MRI interpreted as possible pancreatic mass.
Underwent endoscopic ultrasound on ___ which did not
identify this mass but recommended MRCP to rule out occult mass.
Patient underwent MRCP this admission on ___ which revealed no
mass but instead pancreas divisum and a juxta papillary duodenum
diverticulum, moderate hepatic steatosis, innumerable randomly
distributed renal microcysts typically seen in the setting of
lithium nephropathy
# Klebsiella UTI: The patient's urine was found to be growing
pan-sensitive klebsiella. She denied dysuria but endorsed
possibly increased frequency. Although her leukocytosis resolved
prior to positive culture results (see below), she was treated
with ciprofloxacin x 3 days (last day ___
# Leukocytosis: Patient WBC count on admission was 19.5k. This
downtrended to 13.0k by ___ without treatment aside from IVF.
No fever or localizing symptoms to suggest infection, although
she was found to have klebsiella UTI (see above). On discharge,
WBC count was 9.9
# ___ on CKD: Creatinine on admission was 2.8. Baseline appears
to be ~2.0. Creatinine downtrended to 2.4 by ___ with IVF.
Likely etiology is pre-renal in setting of poor PO intake. At
discharge, creatinine was 2.3.
==== TRANSITIONAL ISSUES ======
# Klebsiella UTI: Pan-sensitive.
- continue ciprofloxacin x 3 days (last day ___
# MRCP results: Showed no pancreatic mass (instead p)ancreas
divisum and a juxta papillary duodenum diverticulum, but did
also show hepatic steatosis and innumerable randomly distributed
renal microcysts (typically seen in the setting of lithium
nephropathy)
- follow up liver and renal findings
- may need continued GI follow-up
# Malnutrition: Albumin of 2.8 on admission. Reported ___ lbs
weight loss over the past 2 months.
- Daily multivitamin with minerals
- Continue TID nutritional supplementation
CODE: ** DNI/DNR **
EMERGENCY CONTACT HCP: ___ (husband, HCP, ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Amitriptyline 30 mg PO QHS
2. BusPIRone 20 mg PO BID
3. Calcitriol 0.25 mcg PO EVERY OTHER DAY
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Lorazepam 0.5 mg PO Q8H:PRN anxiety
6. Propranolol LA 240 mg PO DAILY
7. Zolpidem Tartrate 10 mg PO QHS
8. Pantoprazole 40 mg PO Q24H
9. Senna 8.6 mg PO DAILY
10. Prochlorperazine 10 mg PO Q6H:PRN nausea
11. Ranitidine 150 mg PO DAILY:PRN heartburn
12. Acetaminophen ___ mg PO Q6H:PRN pain/headache
Discharge Medications:
1. Amitriptyline 30 mg PO QHS
2. BusPIRone 20 mg PO BID
3. Calcitriol 0.25 mcg PO EVERY OTHER DAY
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Lorazepam 0.5 mg PO Q8H:PRN anxiety
6. Pantoprazole 40 mg PO Q24H
7. Prochlorperazine 10 mg PO Q6H:PRN nausea
8. Propranolol LA 240 mg PO DAILY
9. Senna 8.6 mg PO DAILY
10. Zolpidem Tartrate 10 mg PO QHS
11. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 capsule(s) by mouth daily Disp
#*30 Capsule Refills:*0
12. Acetaminophen ___ mg PO Q6H:PRN pain/headache
13. Ranitidine 150 mg PO DAILY:PRN heartburn
14. Ciprofloxacin HCl 250 mg PO Q24H Duration: 2 Days
RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- pancreas divisum and a juxta papillary duodenum diverticulum.
- klebsiella urinary tract infection
Secondary Diagnosis:
- Malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted to ___ on ___ after your outpatient
physician identified several abnormalities on your lab tests. We
were able to correct several of these, including your creatinine
(a marker of impaired kidney function). ___ also underwent an
imaging study of your pancreas that revealed no mass.
We feel it is now safe for ___ to return home with close follow
up. It was a pleasure to take care of ___ during your hospital
stay.
Sincerely,
Your ___ Team
Dear ___,
___ were admitted to ___ on ___ after your outpatient
physician identified several abnormalities on your lab tests. We
were able to correct several of these, including your creatinine
(a marker of impaired kidney function). ___ also underwent an
imaging study of your pancreas that revealed no mass.
We feel it is now safe for ___ to return home with close follow
up. It was a pleasure to take care of ___ during your hospital
stay.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10150465-DS-22 | 10,150,465 | 27,771,661 | DS | 22 | 2155-08-02 00:00:00 | 2155-08-02 15:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old woman with stage V CKD (not yet
on dialysis) along with stage IIIA left breast cancer undergoing
neoadjuvant weekly taxol who is admitted from the ED with
shortness of breath.
Patient was admitted ___ - ___ with dyspnea, cough, and
tachycardia. She was ultimately found to have streptococcal
pneumonia. She completed 7 day course of antibiotics with
levofloxacin. She had negative VQ scan and ___ that
admission.
She was evaluated by ___ and discharged home.
Since discharge home, she reports persistent dyspnea on
exertion.
She can walk about ___ feet before getting winded. She denies
SOB at rest. No orthopnea or PND. She had a temperature of 100.0
last ___, no other known fevers. She notes occaisional
intermittent palpitations and atypical chest pain. No other
acute
complaints. No headache or visual changes. No URTI symtoms. No
dysphagia or odynophagia. No N/V/D. Nl BM today. No dysuria. No
new leg pain or swelling. No new rashes.
In the ED, initial VS were pain 0, T 97.3, HR 108, BP 110/64, RR
20, O2 100%RA. Initial labs notable for Na 137, K 5.0, HCO3 22,
Cr 3.1, WBC 3.7, HCT 27.3, PLT 223, Trop 0.03 with MB 1, BNP
4938, DDimer 995. Lactate 1.7. UA 3 RCBC 1 RBC no bacteria
nitrate negative. CXR showed interval improvement of prior
opacities, no edema, and no new focal consolidation. Patient was
given 1L LR and 0.5mg po lorazepam x2. VS prior to transfer were
T 97.8, HR 110, BP 110/68, RR 18, O2 94%RA.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
-She had been getting regular annual mammograms either at ___ or ___. About ___ mo ago she complained of L breast
pruritis to PCP who felt ___ L breast retroareolar mass on exam
-___: Bilateral diagnostic mammogram
FINDINGS: Tissue density: C.
LEFT: There has been interval development of left nipple
retraction compared to the prior mammogram. There has been
interval development of skin thickening, particularly along the
lower inner left breast. There is suggestion of an at least 1.7
x 1.1 x 1.6 cm irregular retroareolar left breast mass which is
not seen on the prior mammogram. Additionally, there is a been
interval development of punctate and amorphous
microcalcifications which extend at least 5 cm from the nipple
on
the CC view. Areas of distortion and possible edema are also
noted, most notably in the upper outer left breast, which also
corresponds to the patient's palpable abnormality. There has
also been interval increase in size of left axillary lymph
nodes.
RIGHT: Postsurgical changes are visualized within the right
breast. There is no definite suspicious mass, unexplained
architectural distortion, or suspicious grouped
microcalcifications within the right breast.
-___: LEFT BREAST ULTRASOUND: At the 2 o'clock
position of the left breast approximately 3 cm from the nipple
corresponding to the patient's palpable abnormality of concern,
there is a 1.1 x 1 x 0.9 cm irregular, spiculated mass with an
anti parallel orientation which is concerning for malignancy.
Multiple additional areas of concern are visualized,
particularly
at the 3 o'clock position of the left breast
approximately 7 cm from the nipple 5:00 position approximately 2
cm from the nipple and 8:00 position 1-10 cm from the nipple
with
associated skin thickening noted. Additionally, there is a 2.4
x
1.7 x 1.8 cm irregular mass with angular margins and internal
vascularity at the 9 o'clock retroareolar position of the left
breast. Finally, there is a 7 mm irregular, hypoechoic
mass containing microcalcifications at the 2 o'clock position of
the left breast approximately 4 cm from the nipple and
correspond
to the microcalcifications of concern on the mammogram.
Additional imaging of the left axilla demonstrates multiple
abnormal appearing lymph nodes.
-___: US guided core bx of 2 L breast masses + FNA of L
axillary node:
Lesion 1: L breast 2'0clock 3 cm from nipple (ribbon clip
placed)-path-grade 3 IDC, 1.1 cm in this limited sample. ER>95%,
PR>95%. HER neg by IHC and FISH (ratio 1.1)
Lesion 2: L breast retroarealoar mass(HydroMark clip
placed)-path-grade 3 IDC (1.2 cm in this limited sample) + high
grade DCIS
Lesion 3: L axillary node FNA (no clip placed)-path-metastatic
carcinoma c/w breast primary. Lymphocytes noted c/w LN sampling.
-___: PETCT - IMPRESSION: 1. Multifocal FDG avid left
breast nodularity is consistent with known breast carcinoma. 2.
Multiple FDG avid left axillary and subpectoral lymph nodes
suggest disease involvement.3. Nonspecific mildly FDG avid soft
tissue overlying the intercostal space of the left lateral fifth
and sixth ribs. 4. 7 mm ground-glass nodule in the right apex
and multiple left lower lobe pulmonary nodules measuring up to 5
mm are nonspecific and too small to characterize with FDG,
though
raise the possibility of neoplastic disease.
-___: Case discussed in breast tumor board. Recs for bx
of
L scapula lesion. Bx request placed but later radiology reviewed
it again and felt very confident that the L scapula lesion
represented a benign entity "elastofibroma dorsi" and bx was
cancelled. Her lung lesions are too small to biopsy and we will
repeat imaging periodically to follow up on them
-___: TTE - EF=60%. Normal global biventricular systolic
function. No pathologic valvular flow.
-___: Port placement
-___: C1D1 of ddAC w neulasta support
-___: C1D8 nadir count check w ANC of 60 Plts of 83K. Pt
afebrile and w/o s/s of infection. Given prophylactic levaquin X
1 week course (250mg Q 48 hours given renal fxn)
-___: C2 ddAC
-___: C3 ddAC
-___: went to ER for sob/fatigue. Anemia worse to 7.9 and
was given 1 unit prbc
-___: C4 ddAC delayed for port site cellulitis
-___: C4 ddAC
-___: Taxol wk1
-___: Taxol ___: Admission for acute pancreatitis complicated by
ileus
-___: Taxol #3
-___: Taxol #4
-___: Taxol #5
-___: Taxol #6 (given while inpatient)
-___: Taxol #___: Taxol #8
PAST MEDICAL HISTORY:
1. Stage IV/V CKD - getting prepared for HD
2. Hypothyroidism
3. Anxiety
4. Migraine
5. Tobacco abuse
6. GERD
7. Idiopathic recurrent pancreatitis status post EUS/ERCP in
___
status post sphincterotomy and sludge removal
8. Reactive airway disease
9. Restless leg syndrome
10. TAH/BSO - ___ years ago for benign tumor
11. Right loop forearm AV graft - ___
12. Right breast cyst aspiration ___ years ago
Social History:
___
Family History:
Sister with history of diabetes mellitus. Mother diagnosed with
pancreatic cancer age ___.
Physical Exam:
ON ADMISSION
=============
VS: T 98.5 HR 106 BP 91/55 RR 20 SAT 97% O2 on RA
GENERAL: Pleasant cachectic woman in no distress sitting up
comfortably
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Dry MM. Oropharynx clear without lesion, JVD not elevated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops
RESPIRATORY: Appears in no respiratory distress, clear to
auscultation bilaterally, no crackles, wheezes, or rhonchi
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding; no hepatomegaly, no
splenomegaly
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Normal bulk
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes
ON DISCHARGE
=============
24 HR Data (last updated ___ @ 1400)
Temp: 97.8 (Tm 98.5), BP: 100/61 (100-126/61-73), HR: 79
(79-84), RR: 20 (___), O2 sat: 97% (97-100), O2 delivery: RA,
Wt: 119.3 lb/54.11 kg
GENERAL: Chronically-ill appearing lady, in no distress lying in
bed comfortably.
HEENT: Anicteric, PERLL, Mucous membranes moist, oropharynx
clear.
CARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, with scant bibasilar ronchi.
ABD: Non-distended, normal bowel sounds, soft, non-tender, no
guarding, no palpable masses, no organomegaly.
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness. Mild tenderness in right anterior thigh. Normal
hip ROM with no pain.
NEURO: Alert and oriented, good attention and linear thought
process. CN II-XII intact. Strength full throughout. Sensation
to
light touch intact.
SKIN: No significant rashes. Right chest wall port without
erythema, secretion or tenderness.
Pertinent Results:
___ 05:35PM BLOOD WBC-3.7* RBC-2.82* Hgb-9.2* Hct-27.3*
MCV-97 MCH-32.6* MCHC-33.7 RDW-14.8 RDWSD-51.9* Plt ___
___ 08:06AM BLOOD WBC-4.0 RBC-2.94* Hgb-9.2* Hct-27.5*
MCV-94 MCH-31.3 MCHC-33.5 RDW-16.3* RDWSD-55.1* Plt ___
___ 05:35PM BLOOD Glucose-91 UreaN-41* Creat-3.1* Na-137
K-5.0 Cl-101 HCO3-22 AnGap-14
___ 08:15AM BLOOD Glucose-91 UreaN-41* Creat-2.8* Na-141
K-4.5 Cl-104 HCO3-25 AnGap-12
___ 05:45AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.2
___ 08:15AM BLOOD Calcium-10.0 Phos-3.8 Mg-2.2
___ 05:35PM BLOOD D-Dimer-995*
Brief Hospital Course:
Mrs. ___ is a ___ year-old lady with a history of COPD (quit
smoking 1mo ago), CKD V, stage III breast cancer currently on
neoadjuvant weekly paclitaxel (___) and recent
pneumococcal pneumonia who presents with dyspnea/fatigue on
exertion.
#Dyspnea/Fatigue on exertion:
#Symptomatic anemia
Patient's report of dyspnea appears equivocal as she seems to
interpret fatigue as dyspnea. Ambulatory O2 sats by RN actually
improved to 100%RA for 98%RA. ___ notes RR up to 28 while doing
stairs with lowest O2 sat of 94% but marked appearance of
fatigue. Her CXR supports improving opacities from recent
pneumonia. Her absence of wheezing, bronchorrhea, cough or
hypercarbia argue against COPD exacerbation. She has no evidence
of DVT on doppler US and she has a low probability (<10%) V/Q
scan. Her ECHO does not show worsening systolic or diastolic
function. A CT chest w/o contrast shows improvement in her
previous pneumonia and no signs of taxane related pneumonitis.
Her symptoms may be more in relation to deconditioning
making her feel fatigue upon minimal effort. Patient declined
ABG for co-oxymetry. Her dyspnea/fatigue improved somewhat after
transfusion of 1U PRBC. She was evaluated and treated by ___ who
recommended home ___ for deconditioning.
#Severe Protein Calorie Malnutrition: In setting of poor
appetitefrom advanced malignancy and chemotherapy. Has continued
losing weight since previous admission.
Seen by nutrition and increased frequence of ensure enlive to 5
bottles daily. Dronabinol for appetite stimulation was increased
to 2.5mg bid.
#Hypovolemia, resolved
Patient appeared clinically volume down on admission and
received 2L NS with resolution.
#Stage V CKD: Her renal function remained stable during her
admission.
#COPD: Not exacerbated. Continued on tiotropium.
#Insomnia
#Anxiety
Continued on lorazepam, zolpidem and buspirone
#h/o Tobacco abuse:
Continued on nicotine patch
TRANSITIONAL ISSUES
=====================
1. Nutrition: Please make sure patient increases ensure intake
from ___ bottles a day to 5 bottles a day. Please arrange for
procurement of fresh fruit and vegetable as those are a few of
the palatable foods to patient. Increased dronabinol to 2.5mg
bid.
2. Her fatigue and discomfort seems to improve with Hb>8,
consider transfusing to goal Hb>8.
3. Leg pain: Has intermittent aches and pains in different spots
of lower extremities that do not respond to acetaminophen. Exam
reassuring. Started on low dose hydromorphone. If persists
consider further work-up +/- renewing hydromorphone.
This patient's complex discharge plan was formulated and
coordinated over the course of 45 minutes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Amitriptyline 30 mg PO QHS
3. Aspirin 81 mg PO DAILY
4. BusPIRone 20 mg PO DAILY
5. Calcitriol 0.25 mcg PO 3X/WEEK (___)
6. Dronabinol 2.5 mg PO QPM
7. Levothyroxine Sodium 75 mcg PO DAILY
8. LORazepam 1 mg PO TID:PRN anxiety
9. Multivitamins 1 TAB PO DAILY
10. Nicotine Patch 21 mg TD DAILY
11. Pantoprazole 40 mg PO Q24H
12. Propranolol LA 120 mg PO DAILY
13. Ranitidine 150 mg PO BID:PRN reflux
14. Senna 8.6 mg PO BID
15. Tiotropium Bromide 1 CAP IH DAILY
16. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
17. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of
breath/wheezing
18. Dexamethasone 8 mg PO AS DIRECTED WITH CHEMOTHERAPY
19. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
Discharge Medications:
1. Ensure Enlive (food supplemt, lactose-reduced) 1 bottle oral
five times a day
RX *food supplemt, lactose-reduced [Ensure Enlive] 0.08 gram-1.5
kcal/mL 1 bottle by mouth five times a day Refills:*0
2. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Severe
RX *hydromorphone 2 mg ___ tablet(s) by mouth up to twice a
day Disp #*30 Tablet Refills:*0
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
4. Dronabinol 2.5 mg PO BID
RX *dronabinol 2.5 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
5. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of
breath/wheezing
7. Amitriptyline 30 mg PO QHS
8. Aspirin 81 mg PO DAILY
9. BusPIRone 20 mg PO DAILY
10. Calcitriol 0.25 mcg PO 3X/WEEK (___)
11. Dexamethasone 8 mg PO AS DIRECTED WITH CHEMOTHERAPY
12. Levothyroxine Sodium 75 mcg PO DAILY
13. LORazepam 1 mg PO TID:PRN anxiety
14. Multivitamins 1 TAB PO DAILY
15. Nicotine Patch 21 mg TD DAILY
16. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
17. Pantoprazole 40 mg PO Q24H
18. Propranolol LA 120 mg PO DAILY
19. Ranitidine 150 mg PO BID:PRN reflux
20. Senna 8.6 mg PO BID
21. Tiotropium Bromide 1 CAP IH DAILY
22. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Subjective dyspnea
Anemia
Deconditioning
Severe protein calorie malnutrition
Stage III Breast Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ were admitted to the hospital for dehydration, fatigue on
exertion and musculoskeletal pain.
After a long and thorough work-up we found that your fatigue or
shortness of breath on exertion is not due to heart or lung
issues. It is probably due to deconditioning from inactivity and
poor nutrition.
We gave ___ a unit of blood. ___ were seen by the nutrition
specialist who recommended going up on your ensures to 5 bottles
a day. Our physical therapist also recommended home physical
therapy.
It was a pleasure to take care of ___ and we wish ___ the best.
Followup Instructions:
___
|
10150503-DS-7 | 10,150,503 | 29,926,898 | DS | 7 | 2117-04-03 00:00:00 | 2117-04-04 01:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug) / morphine
Attending: ___.
Chief Complaint:
Bradycardia
Major Surgical or Invasive Procedure:
Pacemaker placement - ___
History of Present Illness:
Ms. ___ is a ___ with PMhx IDDM and PMR, HTN, who
presents as transfer from ___ due to
bradycardic arrest. She presented earlier today to ___.
Per patient, her children had just left around noon on ___ when
she began experiencing blurry visions and making mistakes while
knitting. She felt extremely lightheaded and weak like she was
about to pass out, but did not lose consciousness or fall but
managed to grab onto nearby furniture for support and sink into
a
nearby chair. She then endorsed profuse non-bloody, non-bilious
emesis. She was so weak/lightheaded she could barely make her
way
to the phone but managed to called her daughter from home and
told them she was not feeling well. Was bradycardic to ___ when
EMS arrived but decreased to ___ during episodes of retching,
BPs
stable, no LOC, CP, SOB, abd pain, dysuria/hematuria, no recent
f/c, although patient mentioned her daughter noticed she
appeared
flushed before she left.
In the ED at ___, she was noted to be in sinus brady to
___, borderline hypotensive, symptomatic with nausea/dry
heaving,
followed by a 10 sec episode of asystole with no pulse palpated,
although EKGs during the episode reportedly showed sinus
bradycardia (no strips available). During this episode, patient
lost consciousness and pulse, recovered with CPR (~10sec, no
shocks/meds administered) to HR ___. The on call cardiologist
was
consulted and found the patient alert, answering questions.
Transcutaneous pacing did not work so a temporary pacer wire was
placed in the left IJ. Vitals subsequently were HR 80, BP
131/78,
with normal O2. VBG 7.36/45/71. Still with some nausea that
improved with Phenergan. Transferred to ___ for further eval
and management. HDS in transport with some intrinsic beats and
about 80% paced beats. No longer nauseous on arrival. EP
consulted in ED and adjusted pacer settings from DDD mode at a
rate of 84 bpm to VVI mode at a rate of 60, at time of transfer,
noted to have 70% intrinsic beats.
On arrival to the CCU, patient was tired but comfortable,
denying
lightheadedness, SOB, nausea, abd pain. Confirmed the above
history except she could not recall the events at ___,
does not remember passing out or receiving CPR. Wears R hearing
aid. This morning, telemetry notable for somewhat more frequent
paced beats.
Past Medical History:
- No known cardiovascular disease
- Diabetes mellitus, on insulin.
- Glaucoma.
- Cataracts, s/p L eye surgery.
- Polymyalgia rheumatica.
- HTN: only started taking BP meds in the past ___ years
PSH:
- R knee arthroscopy.
- R carpal tunnel surgery.
- Appendectomy.
Social History:
___
Family History:
Mother: MI
No h/o sudden deaths
Family history of long life
2 older sisters who live independently.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VS: Reviewed in Metavision, T 98.9, BP 142/58, HR 66, RR 21, O2
Sat 100% on RA
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic, atraumatic. Sclera anicteric.
NECK: Supple. JVP not elevated, L IJ temp wire in-place c/d/i
CARDIAC: RRR. No murmurs, rubs, or gallops.
LUNGS: No chest wall deformities. Respiration is unlabored with
no accessory muscle use. Faint bibasilar crackles
ABDOMEN: Soft, non-tender, mildly distended. No palpable
hepatomegaly or splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, trace
peripheral edema in ___ and ankles bilaterally
SKIN: No significant lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
NEURO: Alert, thought it was ___, answering questions
appropriately, recounting earlier events, moves all extremities
DISCHARGE PHYSICAL EXAM
=======================
GENERAL: Well developed, well nourished in NAD. Oriented x3.
HEENT: NC/AT. Sclera anicteric.
NECK: Supple. JVP not elevated, site of L IJ temp wire removal
c/d/i, appropriately tender
CARDIAC: RRR. No murmurs, rubs, or gallops.
LUNGS: No chest wall deformities. Respiration is unlabored with
no accessory muscle use. Clear to auscultation
ABDOMEN: Soft, NTND. No palpable hepatomegaly or splenomegaly.
EXTREMITIES: WWP. No clubbing, cyanosis, or edema, improved
erythema and swelling in R lateral malleolus, tender to
palpation
but not with dorsiflexion.
SKIN: Erythema on R lateral malleolus
PULSES: Distal pulses palpable and symmetric.
NEURO: Alert, answering questions appropriately, moves all
extremities
Pertinent Results:
ADMISSION LABS
================
___ 11:25PM BLOOD WBC-14.5* RBC-4.56 Hgb-12.6 Hct-41.0
MCV-90 MCH-27.6 MCHC-30.7* RDW-13.0 RDWSD-42.6 Plt ___
___ 11:25PM BLOOD Neuts-87.2* Lymphs-7.7* Monos-3.6*
Eos-0.4* Baso-0.6 Im ___ AbsNeut-12.61* AbsLymp-1.11*
AbsMono-0.52 AbsEos-0.06 AbsBaso-0.08
___ 11:25PM BLOOD Plt ___
___ 11:25PM BLOOD Glucose-200* UreaN-16 Creat-0.7 Na-137
K-4.9 Cl-105 HCO3-16* AnGap-16
___ 11:25PM BLOOD ALT-41* AST-72* AlkPhos-86 TotBili-0.5
___ 11:25PM BLOOD Albumin-3.8
___ 05:30AM BLOOD TSH-0.42
___ 11:34PM BLOOD Lactate-1.5
DISCHARGE LABS
===============
___ 06:36AM BLOOD WBC-8.0 RBC-3.84* Hgb-10.9* Hct-34.3
MCV-89 MCH-28.4 MCHC-31.8* RDW-13.3 RDWSD-43.2 Plt ___
___ 06:36AM BLOOD Plt ___
___ 06:36AM BLOOD ___ PTT-24.9* ___
___ 06:36AM BLOOD Glucose-108* UreaN-30* Creat-0.9 Na-141
K-4.1 Cl-108 HCO3-22 AnGap-11
___ 06:36AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.0
MICROBIOLOGY
============
UCx (___) - NGTD
IMAGING
========
TTE (___)
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global biventricular systolic
function. Moderate pulmonary artery systolic hypertension.
Mildmoderate aortic regurgitation with mildly thickened
leaflets. No definite structural cardiac source
of embolism identified.
Ankle XR (___)
No previous images. The bony structures and joint spaces are
essentially
within normal limits and the ankle mortise is intact. No
evidence of
calcaneal spurring. Substantial vascular calcification is seen
about the ankle.
CXR (___)
The tip of a single pacemaker lead placed through a left IJ
central venous
catheter projects over the right ventricle.
Brief Hospital Course:
for Outpatient Providers: Ms. ___ is a functional ___ yo woman
with history of IDDM, PMR, HTN, transferred from ___
___ due to reported bradycardic arrest s/p temporary pacer
wire placement w/ permanent pacemaker placed this admission.
ACUTE ISSUES:
=============
#Bradycardic arrest vs symptomatic Bradycardia:
Pt presented from ___ s/p "asystolic arrest", which
resolved in <30s without compressions, medications or shocks, pt
did lose consciousness, but unclear if actually arrested vs more
likely symptomatic bradycardia as we were unable to obtain
strips. Pt denied any preceding symptoms to suggest vagal
episode. Our suspicion is that the pt may have had a temporary
heart block, possibly due to underlying sick sinus syndrome. She
had a temporary pacing wire place at ___ and underwent
permanent pacemaker placement ___ without complication. TTE
this admission showed mild symmetric LVH with normal cavity size
and regional/global biventricular systolic function (LVEF
69%)and moderate PA systolic HTN. Scheduled for follow up in
device clinic within one week of discharge.
#HTN: Pt had brief episode of hypotension this admission
(80s/___ requiring IVF), and her Lisinopril and amlodipine were
held. She was restarted on lisinopril 20mg with almodipine held
on discharge.
#R ankle pain #Home Safety Patient developed R ankle pain,
swelling around R lateral malleolus, which was tender to
palpation. Ankle XR wnl. Initially limiting ability to walk, ___
recommended home with ___ and 24hr supervision. Per discussions
w/ family and pt, she very much preferred home and ___ services
were arranged. By discharge, patient reported being able to walk
without difficulty.
#Normocytic anemia: Pt w/ erratic normocytic anemia this
admission, Hgb ranging 9.6-12.6, stable after pacemaker
placement, no clinical evidence of bleeding or pocket hematoma.
CHRONIC ISSUES:
===============
#IDDM: On levemir 8U QHS and mealtime Homolog (per patient
typically 7U) at home. These were not changed inpatient, also
utilized insulin sliding scale.
#Glaucoma: Continued home eye drops
TRANSITIONAL ISSUES:
====================
[] No post-PPM antibiotic prophlyaxis needed
[] Patient discharged on dose reduction of Lisinopril (on 20mg,
was previously on 20mg BID at home). Her home amlodipine was
also held. Would consider more lenient blood pressures goals
given age and fraility.
[] If patient continues to be hypertensive, can uptitrate
lisinopril while continuing to hold amlodipine.
[] ___ services set up for pt, ___ recommending rehab, however
pt/family preferences of home ___ w/ ___ services
[] Pt will have follow-up in device clinic in one week
Labs:
[] Needs BMP, Cr checked in 1 week at follow-up appointment
#CODE: Full (confirmed)
#CONTACT/HCP: ___ (___)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic (eye) TID
3. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
4. Glargine 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Lisinopril 20 mg PO BID
6. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE 1X/WEEK
(MO)
Discharge Medications:
1. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic (eye)
TID
3. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
4. Glargine 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE 1X/WEEK
(MO)
6. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do
not restart amLODIPine until you discuss with your doctor
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS:
==================
Bradycardia
SECONDARY DIAGNOSIS:
====================
Hypertension
Diabetes
Glaucoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Thank you for letting us participate in your care!
WHY WAS I ADMITTED TO THE HOSPITAL
- Your heart rate was very slow and you needed a pacemaker
WHAT WAS DONE FOR ME WHILE I WAS HERE?
- You had a temporary pacemaker placed with a wire in your neck
- We monitored you closely in the ICU
- You had a permanent pacemaker placed to keep your heart rate
from going too slow
WHAT SHOULD I DO WHEN I GO HOME?
- No heavy lifting with your left arm for one week
- Please take all of your medications as prescribed.
- Please attend your outpatient follow-up appointments (see
below).
We wish you the very best!
Sincerely,
- Your ___ care team
Followup Instructions:
___
|
10150563-DS-15 | 10,150,563 | 24,925,572 | DS | 15 | 2204-03-30 00:00:00 | 2204-04-02 08:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin
Attending: ___.
Chief Complaint:
possible encephalopathy, toxic or metabolic
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a very pleasant ___ with dementia (but currently
living alone in a ___, hypothyroidism, and DJD/LBP who
presents to ED with 5days of confusion, poor PO intake, and not
taking meds during this time. Son found her to be very pale
appearing today and with confusion off her baseline - forgetful.
Saw her PCP and was referred to ED. In the s/o confusion, pt has
had incontinence of urine and feces. No worsening of back pain.
In the ED, oriented x 1, unable to name building and
rambles/circumstantial but with linear confusional TPs, believes
it is ___. Neuro exam with R facial droop (baseline per son
with ___, other CNs intact, ___ motor intact, sensory
intact, baseline tremor. Rectal tone intact. Pt denies cough,
SOB, CP, n/v, abd pain, diarrhea. She does endorse occassional
dysuria. No f/c.
Past Medical History:
Dementia
Unsteady gait, uses walker
Spondylitic myelopathy
Hypothyrodism
LBP, Lumbar DJD
Macular Degeneration
MVP
Migraines
Osteopenia
Anemia, referred to Dr. ___, thought to be due to Valproic
Acid
F/b ENT for hearing loss, hoarse voice
OAB, on Detrol, f/b Dr. ___ ___, revised in ___
___ Palsy
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION
Vitals: 98.3 129/75 66 20 100%RA
GENERAL: NAD, oreineted to self, knew she was in a hospital, but
thought it was the 1900s
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
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: L previous present facial droop c/w known palsy, no
cogwheel rigidity, notable resting tremor, worse with intention
but also present at rest, motor/sensation grossly intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Exam:
Vitals: 98.8 114/48 64 20 95%RA
GENERAL: WD WN, in NAD
HEENT: NCAT, EOMI, anicteric sclera
CARDIAC: RRR, no murmurs
LUNG: CTAB no w/r/r
ABDOMEN: nondistended, +BS, nontender
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: Oriented to person only. Inattentive (negative ___
backwards). Alert. L facial droop c/w known palsy, resting
tremor, worse with intention
SKIN: warm and well perfused, no rashes
Pertinent Results:
==========================================
LABS
==========================================
Admission
___ 08:29PM BLOOD WBC-4.0 RBC-3.43* Hgb-11.5* Hct-33.2*
MCV-97 MCH-33.5* MCHC-34.6 RDW-13.5 Plt ___
___ 08:29PM BLOOD Neuts-58.4 ___ Monos-11.1*
Eos-0.8 Baso-0.3
___ 08:29PM BLOOD Glucose-108* UreaN-33* Creat-1.0 Na-138
K-3.8 Cl-97 HCO3-30 AnGap-15
___ 08:29PM BLOOD ALT-21 AST-33 LD(LDH)-248 AlkPhos-59
TotBili-0.1
___ 08:29PM BLOOD Albumin-4.0 Calcium-9.2 Phos-3.0 Mg-2.0
___ 08:29PM BLOOD TSH-3.9
Discharge
___ 05:09AM BLOOD WBC-4.8 RBC-3.41* Hgb-11.1* Hct-32.7*
MCV-96 MCH-32.4* MCHC-33.9 RDW-12.9 Plt ___
___ 05:09AM BLOOD Glucose-84 UreaN-18 Creat-0.7 Na-140
K-3.6 Cl-100 HCO3-27 AnGap-17
___ 05:09AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.0
Micro
BCX x2 no growth
UCX x1 no growth
==========================================
STUDIES
==========================================
___ Imaging CHEST (PA & LAT)
No acute cardiopulmonary abnormality.
___ Imaging CT HEAD W/O CONTRAST
No acute intracranial abnormality. Atrophy and chronic small
vessel ischemic disease.
Brief Hospital Course:
SUMMARY
___ year old female with past medical history of dementia,
migraines admitted ___ w acute metabolic encephalopathy,
found to have a UTI, treated with three day course of
ceftriaxone, now mental status improving to baseline,
recommended for discharge to ___ rehab, discharged on
___.
Acute Metabolic Encephalopathy - patient presented w change in
her baseline mental status. Workup revealed head CT without
acute process, no recent medication changes, no electrolyte
disturbances, UA concerning for UTI as below. Progresssion of
underlying dementia may have also contributed but would not
explain acute worsening. She was treated for a UTI as below
with improvement to her baseline.
2. Urinary and fecal incontinence: Most likely due to altered
mental status and UTI. In light of low back pain and DJD as
above, she received a full neurologic exam including rectal
tone; there was no evidence of lower extremity weakness or
decreased rectal tone to suggest cord compression. Monitored
for improvement during hospitalization. Improved with rest,
hydration, oral intake, reorientation, and mobilization.
3. UTI: On admission she complained of mild dysuria, with UA
concerning for possible infection. She received three days with
ceftriaxone with improvement in symptoms. Cultures grew out
polymicrobial consistent with contamination..
4. Dementia: She is followed by Neurology at ___, takes
memantine and donepezil. She was continued on these medications
in the hospital. Per her son, her baseline mental status varies
between confabulation and word-finding difficulty. Difficult to
distinguish, as word finding difficulty manifests as lengthy
circumlocution, during which interlocutor will have to guess the
subject or object she is trying to discuss. She can sometimes
name the object after being allowed time for recall. He notes
that her current mental status is on the same spectrum as her
baseline but worse. The patient was evaluated by physical
therapy and deemed appropriate for rehab, to which she was
discharged. Per physical therapy, she is unsafe to live
independently, as she cannot perform basic tasks related to
safety (for example, cannot name her ___ bracelet or
describe its purpose).
CHRONIC
# Back Pain: Secondary to known DJD, only on Gabapentin.
Acetaminophen for now, holding gabapentin (though renal function
and medication dose unchanged, low suspicion for exacerbating
AMS). Fall precautions given unsteady gait
# Migraines: Cont Divalproex for ppx
# Tremor: Cont Propanolol.
TRANSITIONAL
- needs home safety eval post rehab
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Divalproex (DELayed Release) 250 mg PO DAILY
2. Donepezil 10 mg PO DAILY
3. Gabapentin 200 mg PO TID
4. Levothyroxine Sodium 88 mcg PO DAILY
5. Memantine 5 mg PO DAILY
6. Propranolol 10 mg PO DAILY
7. Propranolol 20 mg PO QPM
8. Tolterodine 4 mg PO DAILY
9. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg (1,500
mg)-800 unit oral BID
10. PreserVision Lutein (vit C-vit E-copper-ZnOx-lutein)
226-200-5-0.8 mg-unit-mg-mg oral DAILY
Discharge Medications:
1. Divalproex (DELayed Release) 250 mg PO DAILY
2. Levothyroxine Sodium 88 mcg PO DAILY
3. Propranolol 20 mg PO QPM
4. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg (1,500
mg)-800 unit oral BID
5. Donepezil 10 mg PO DAILY
6. Gabapentin 200 mg PO TID
7. Memantine 5 mg PO DAILY
8. PreserVision Lutein (vit C-vit E-copper-ZnOx-lutein)
226-200-5-0.8 mg-unit-mg-mg oral DAILY
9. Tolterodine 4 mg PO DAILY
10. Acetaminophen 1000 mg PO Q8H:PRN pain
11. Propranolol 10 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Possible Encephalopathy, toxic or metabolic
Urinary tract infection
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for confusion. We could find no cause
of this except for a possible urinary tract infection, for which
we administered antibiotics. We think this represents some
worsening of your dementia, which is expected over time. You
should follow closely with your Primary Care Physician.
Please see your appointments and medications below.
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
10150567-DS-20 | 10,150,567 | 24,904,661 | DS | 20 | 2156-04-09 00:00:00 | 2156-04-09 16:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Phenobarbital / Valium / Haldol
Attending: ___.
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o male with a past medical history of
seizure disorder and MR who presents with BRBPR. Patient is
nonverbal and unable to provide history. Patient's mother
reports that he has been having maroon stools requiring diaper
change q30min-1h. She states that he has never had GI bleeding
like this in the past. Patient has undergone multiple
colonoscopies in the past but has had poor prep.
In the ED, initial vitals were: T 98.1, HR 109, BP 114/71, RR
16, 100% RA.
- Labs were significant for Hb 11.8 --> 11.2 (baseline Hb
___.
- GI was consulted and recommended admission for monitoring and
will discuss colonoscopy. Also recommended obtaining a CTA and
___ intervention if brisk bleed.
- The patient was given pantoprazole 40 mg IV x1.
Vitals prior to transfer were: HR 87, BP 105/69, RR 20, 99% RA.
Upon arrival to the floor, T 98.3, BP 113/71, HR 92, RR 18, 95%
RA, 60 kg. Patient was resting in bed, nonverbal and curled up.
Two loose bowel movements this AM which per report were maroon
in appearance but none since.
Past Medical History:
Hypertension.
Hypercholesterolemia.
Onychomycosis.
Seizure disorders.
Seasonal allergies.
Left and right ulnar fractures.
Mental Retardation
Esophagitis
Chronic constipation
Iron deficiency Anemia
Social History:
___
Family History:
No history of IBD
Physical Exam:
Vitals: T 98.3, BP 113/71, HR 92, RR 18, 95% RA, 60 kg
General: sleeping but arousable, curled up in bed, nonverbal,
thumb in mouth
HEENT: able to track with eyes, sclera anicteric, thumb in
mouth, dry mucus membranes
Heart: only able to auscultate in RUSB, RRR, normal S1 and S2,
no murmurs
Lungs: poor effort however clear w/o w/r/r
Abdomen: thin, soft, nontender to palpation, normal bowel sounds
Genitourinary: wearing a diaper, no stool in diaper
Extremities: no peripheral edema, no cyanosis or clubbing, warm
Neurological: unable to follow exam, however no gross cranial
nervice deficits, moving arms/legs spontaneously
Dishcarge:
Vitals: 97.4 100/64 73 20 97% RA
General: nonverbal
HEENT: able to track with eyes, sclera anicteric, thumb in
mouth,
Heart: normal S1 and S2, no murmurs
Lungs: poor effort however clear w/o w/r/r
Abdomen: nontender to palpation, normal bowel sounds
Genitourinary: wearing a diaper
Extremities: no peripheral edema, no cyanosis or clubbing, warm
Neurological: unable to follow exam, however no gross cranial
nervice deficits, moving arms/legs spontaneously
Pertinent Results:
Admission:
___ 07:25PM WBC-9.3 RBC-3.56* HGB-11.2* HCT-32.6* MCV-92
MCH-31.4 MCHC-34.3 RDW-16.1*
___ 07:25PM PLT COUNT-156
___ 05:02PM ___ COMMENTS-GREEN TOP
___ 05:02PM LACTATE-1.6
___ 04:41PM GLUCOSE-93 UREA N-28* CREAT-1.1 SODIUM-138
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-26 ANION GAP-15
___ 04:41PM estGFR-Using this
___ 04:41PM ALT(SGPT)-15 AST(SGOT)-21 ALK PHOS-93 TOT
BILI-0.3
___ 04:41PM LIPASE-44
___ 04:41PM ALBUMIN-4.6
___ 04:41PM WBC-10.6 RBC-3.80* HGB-11.8* HCT-34.7* MCV-91
MCH-31.1 MCHC-34.1 RDW-16.0*
___ 04:41PM NEUTS-64.4 ___ MONOS-8.7 EOS-1.3
BASOS-0.4
___ 04:41PM PLT COUNT-187
___ 04:41PM ___ PTT-32.6 ___
Discharge:
___ 05:30AM BLOOD WBC-5.3 RBC-3.62* Hgb-11.6* Hct-36.6*
MCV-101*# MCH-32.0 MCHC-31.6 RDW-15.9* Plt ___
___ 05:30AM BLOOD Plt ___
___ 05:30AM BLOOD Glucose-80 UreaN-15 Creat-1.2 Na-145
K-4.7 Cl-105 HCO3-27 AnGap-18
___ 05:30AM BLOOD Calcium-9.3 Phos-2.9 Mg-2.4
Brief Hospital Course:
Mr. ___ is a ___ y/o male with a past medical history of
seizure disorder and MR who presents with BRBPR
# BRBPR: likely lower GI bleed, possibly diverticular given
history of chornic constipation; however, it is impossible to
say the exact etiology. He remained hemodynamically stable with
a stable Hct. He has had prior colonoscopy attempts, but without
good prep and given his Fe Def anemia of unknown etiology, it
would be prudent to get a good bowel prep and look for an occult
source of bloos loss. After consulting GI, we attempted such
with 2 days of prep with MoviPrep, Lactulose, Mag Citrate, 2
tap water enemas and multiple oral medications; however, we were
still unable to get a good prep. KUB not concerning for
obstruction. After dicussing with the family, they elected not
to continue with another day of prep, but instead to employ
watchful waiting and bring him back should he have another GI
bleed.
We maintained TxS, PIV access, trended his H&H, and monitored
his vitals.
He will be discharged with GI and PCP ___.
TRANSITIONAL ISSUES:
-Monitor CBC at follow up appointment.
-Adjust bowel regimen as needed for constipation
-Consider outpt colonoscopy
-BP med held ___ to GI bleed on admission and he remined 110s
throughout admission, thus ACEi held at discharge. Restart as
needed per PCP.
Billing: Greater than 30 minutes were spent coordinating Mr
___ discharge from the hospital.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 140 mg PO DAILY
2. Loratadine 10 mg PO DAILY:PRN allergies
3. Omeprazole 20 mg PO BID
4. Polyethylene Glycol 17 g PO DAILY
5. DiphenhydrAMINE 25 mg PO QHS:PRN insomnia
6. Enalapril Maleate 5 mg PO DAILY
7. Hydrocortisone Cream 1% 1 Appl TP BID:PRN itching
8. Ketoconazole 2% 1 Appl TP BID PRN
9. Senna 8.6 mg PO DAILY:PRN constipation
Discharge Medications:
1. DiphenhydrAMINE 25 mg PO QHS:PRN insomnia
2. Ferrous Sulfate 140 mg PO DAILY
3. Hydrocortisone Cream 1% 1 Appl TP BID:PRN itching
4. Polyethylene Glycol 17 g PO DAILY
5. Docusate Sodium 200 mg PO BID
6. Senna 17.2 mg PO BID
7. Loratadine 10 mg PO DAILY:PRN allergies
8. Omeprazole 20 mg PO BID
9. Ketoconazole 2% 1 Appl TP BID PRN
Discharge Disposition:
Home
Discharge Diagnosis:
Lower GI Bleed
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You came to us with bright red bleeding from your bottom. Here
you were stable and your blood levels were only slightly low,
which stabilized and began to rise within 24 hours of admission.
Our GI doctors saw ___ and decided a colonoscopy would be best,
however, we were unable to get a good bowel prep. You decided
that since you had no additional bleeds, that your blood levels
arestable, and that your vital signs remained stable, a
colonoscopy is not emergently needed; however, we still do not
know the reason you had a bleed and one reason could be a polyp
or a cancer. You will follow up in GI clinic and with your PCP
for further care. Should this happen again, please come to the
ER immediately.
We wish you all the best,
Your ___ Team.
Followup Instructions:
___
|
10150767-DS-27 | 10,150,767 | 24,421,797 | DS | 27 | 2135-01-31 00:00:00 | 2135-02-01 07:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Keflex / Augmentin / lisinopril
Attending: ___.
Chief Complaint:
pre-syncope/syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with complicated past hx, roux-en-y gastric bypass in ___
c/b post-op PE and upper GIB at anastamosis site due to the
lovenox requiring INR reversal and IVC filter placement (now
removed); recent visits to several ERs for hypertension,
near-syncope; came back ___ because she states she passed
out twice, both during bowel movements. Denies head trauma, does
have R paraspinous neck pain and right shoulder pain, was taking
percocet for that. On zofran for nausea. Decreased PO intake for
the last 3 days. Decreased urine output as well. Stated to
nightfloat that she vomited twice which is not unusual for her.
States to me that she has been vomiting for the past two days
PTA, but then reports that she was not vomiting 2 days ago.
Pt was initially seen at ___ or so ago for congestion
and was started on azithromycin. She then went to ___
___ few days ago and had 2d stay for shortness of breath/cp
where she had negative workup with 2 trops, cxr. BP was high as
high as SBP 200s and HRs as low as ___. Pt was started on
lisinopril 5mg qd and propanolol dose decreased from 20mg tid to
10mg tid. She was also changed from azithmycin to levofloxacin.
She is on propanolol for anxiety, and her clonazepam rx was
stopped 3 wks ago due to overdose with EtOH. She states that she
discussed her visit to the ED for chest pain with her
psychiatrist and that she was told it was unrelated to anxiety.
She was seen in our ED two days ago for hypertension.
In the ED, initial vital signs were 98.5 68 123/77 16 97% RA.
She received Zofran 8mg for nausea, morphine 5mg for right
shoulder pain. EKG was unremarkable. Rectal exam showed
external, small internal hemorrhoids and trace red blood.
Orthostatics demonstrated a pulse increase by 20. VS on transfer
were: 98.0 58 148/82 18 98%.
On the floor, pt is comfortable and well appearing. She
complains of ___ pain in her shoulder but does not appear to
be in any distress. She endoreses recent subjective
fevers/chills, palpitations, n/v, but no diarrhea. She states
that she was concerned when she went home from ___ and had
presyncope and then sycopized while moving her bowels. She
states her LOC was for about a minute, and that she woke up
immediately. She states that her hypertensive symptoms correlate
with flushing, sweating, heart racing. Notably she has had two
previous workups for pheochromocytoma which have been negative.
Per patient, she has been working this up with her PCP and she
still needs to complete a 24-hour urine collection, however
every time she is supposed to have an appointment "something
happens" and she ends up in the ED. She was supposed to have an
appointment today at 8:40am.
She is not sure what happened to her right shoulder but notes it
started when she was in a patient's room flushing a G-tube and
that was when she had the onset of chest pain that brought her
into the ED. She notes little red blood in the stool and notes
that she has hemorrhoids.
Review of Systems:
(+) per HPI
(-) headache, vision changes, rhinorrhea, congestion, sore
throat, cough, shortness of breath, chest pain, abdominal pain,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
1. Pulmonary embolism in ___. tx with heparin, then coumadin x
6 months
2. Asthma; rarely uses albuterol nebulizer treatment
3. Migraine headache
4. Upper GI bleeding due to PUD
5. s/p gastric bypass surgery in ___ at ___
6. s/p panniculectomy and medial thigh lift with butt
autoaugmentation surgery
7. Depresion with anxiety and panic attacks
8. Chronic low back pain
9. Bipolar
10. ADHD
11. s/p Hernia Repair
Social History:
___
Family History:
Only significant for asthma with her sister. Otherwise, no CAD,
DM, cancer in her family.
Physical Exam:
Admission Physical Exam:
Vitals- T 98.9 BP ___ P ___ RR 18 98% RA
General- Alert, oriented, no acute distress, appears very
comfortable in bed
HEENT- Sclera anicteric, MMM, oropharynx clear, EOMI, head
normocephalic, atraumatic
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- ___ short systoic murmur best heard at ___ and LUSB without
radiation to carotids. Regular rate and rhythm, normal S1 + S2
Abdomen- soft, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly. No abdominal bruits.
mild epigastric tenderness with voluntary, poorly timed wincing
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Right shoulder: No pain on palpation, no step offs or
deformities. Full ROM. Positive neers sign. Negative arm drop.
No pain with passive or active ROM however resists ROM saying "I
can't move it" but is able to fully lift arm.
Discharge Physical Exam:
Vitals- T 98 98-101/46-52 ___ RR ___ 98-99% RA. 30mg
oxycodone over 24 hrs
General- Alert, oriented, no acute distress, appears very
comfortable in bed
HEENT- Sclera anicteric, MMM, oropharynx clear, EOMI, head
normocephalic, atraumatic
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- ___ short systoic murmur best heard at ___ and LUSB without
radiation to carotids. Regular rate and rhythm, normal S1 + S2
Abdomen- soft, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly. No abdominal bruits.
mild epigastric tenderness with voluntary, poorly timed wincing
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
___ 04:15PM BLOOD WBC-9.2 RBC-4.88 Hgb-14.6 Hct-43.3
MCV-89# MCH-29.9# MCHC-33.7# RDW-15.7* Plt ___
___ 04:15PM BLOOD Neuts-70.8* ___ Monos-5.0 Eos-0.6
Baso-0.4
___ 04:15PM BLOOD Glucose-86 UreaN-11 Creat-0.7 Na-139
K-4.6 Cl-102 HCO3-23 AnGap-19
___ 04:15PM BLOOD Calcium-9.9 Phos-3.0# Mg-2.2
___ 03:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 03:30PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-150 Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
___ 03:30PM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-2
___ 03:30PM URINE UCG-NEG
___ CXR: FINDINGS:
The cardiac, mediastinal and hilar contours are normal.
Pulmonary vascularity is normal. Lungs are clear. No pleural
effusion or pneumothorax is identified. There are no acute
osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
___ Echo: The left atrium is normal in size. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). There is no left ventricular
outflow obstruction at rest or with Valsalva. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
Brief Hospital Course:
___ yo woman seen at multiple hospitals for symptoms of chest
pain, hypertension, congestion, palpitations, presents with
syncope x2 associated with defecation.
# Syncope: Defecation associated, so most likely reflex syncope.
ECG benign. QT WNL. Patient was recently on monitor at OSH for
two days with no events. Echo essentially normal ruling out
structural abnormality. In setting of vomiting and poor PO
intake, ketosis and mild orthstasis which resolved with IVF.
Repeated episodes of near syncope making patient very nervous
and did not want to syncopize around children. Encouraged
increased fluid and PO intake as well as caution in the home.
Multiple extensive workups for labile BPs and flushing/sweating
that have been negative, though patient requesting further
workups for her previous symptoms. She did note that her BPs had
been stable this admission.
.
# Congestion for three weeks: Continued her course however
likely viral illness "going around" her family.
.
# Hypertension: Most likely essential HTN given her age and
family history. Her report of symptoms has elements concerning
for pheochromocytoma but this was worked up without any finding.
She has no bruits. Continue to suspect secondary causes at this
time as she just started lisinopril and has no physical exam
findings or lab findings concerning for an endocrinopathy or
RAS, and no chest x ray findings or pulse dissociation to invoke
coarct of aorta. Blood pressure has had wide fluctuations and
there may be some autonomic component at work. Continued
lisinopril. Outpatient tilt table may be considered to workup
autonomic dysfunction, however close outpatient monitoring and
reassurance as mentioned above may be as effective. .
.
# Vomiting : Pt states that she normally does vomit since her
gastric bypass. No diarrhea to make argument for viral GI bug.
Symptoms resolved with antiemetics and IVF.
.
# Anxiety: Continued home propanolol.
.
# GERD: Continued Ranitidine and Sucralfate 1 gm PO QID
.
# Right shoulder pain: On exam, most likely nerve impingement
from tendonitis with FROM, unable to elicit true source on exam.
Continued home pregabalin and tizanidine. Reported taking
oxycodone as well however could not verify, unclear who is
prescribing. Was treated with this for pain while in house
however discharged without oxycodone.
.
Transitional Issues:
- close f/u with PCP for monitoring of symptoms
- reassurance and continued f/u with psychiatry
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levofloxacin 750 mg PO Q24H Duration: 3 Days
2. Lisinopril 5 mg PO DAILY
3. Propranolol 10 mg PO TID
4. Pregabalin 75 mg PO BID
5. Ranitidine 150 mg PO DAILY
6. Sucralfate 1 gm PO QID
7. Tizanidine 8 mg PO TID
8. Zolpidem Tartrate 5 mg PO HS:PRN sleep
Discharge Medications:
1. Levofloxacin 750 mg PO Q24H Duration: 3 Days
2. Lisinopril 5 mg PO DAILY
3. Pregabalin 75 mg PO BID
4. Propranolol 10 mg PO TID
5. Sucralfate 1 gm PO QID
6. Tizanidine 8 mg PO TID
7. Zolpidem Tartrate 5 mg PO HS:PRN sleep
8. Ranitidine 150 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: syncope
Secondary diagnosis: s/p bariatric surgery, depression, asthma
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 in the hospital. You were
admitted for evaluation of your heart after fainting while you
were on the toilet. Imaging and other testing of your heart was
normal, which is reassuring. You were also having nausea and
vomiting, which was treated and your nausea improved. You were
given fluids overnight to help you feel better.
Please make sure to go to your clinic appointments and follow up
with Dr. ___.
Please see the attached sheet for your updated medication list.
There were NO CHANGES made to your medications.
Followup Instructions:
___
|
10150842-DS-4 | 10,150,842 | 25,200,625 | DS | 4 | 2126-12-06 00:00:00 | 2126-12-07 07:32:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa(Sulfonamide Antibiotics) / aspirin
Attending: ___.
Chief Complaint:
fainted and hit head
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is an ___ with hx of carotid body surgery, recent
cataract surgery last week who initially presented to OSH after
syncopal episode. Patient reports she was sitting in chair when
she noted crampy abdominal pains. She went to bathroom, had a
dark BM. She stood up and immediately felt lightheaded, profuse
diaphoresis and generalized weakness. She then blacked out and
fell to floor and cannot recall events during the fall, she
struck her left eyebrow during the fall. Her son, who lives
upstairs, heard the fall and immediately came down. She arose to
his voice, exhibited no loss of bladder/bowel continence, did
not have evidence of post-ictal confusion and did not show signs
of myoclonic/tonic movements. She presented to OSH where the
laceration over right eye was sutured and CT showed C6 neck fx.
Stool was dark brown and loose without frank blood. Since the
fall she reports nausea and vomiting bilious fluid. Abdominal
pain have subsided and she has been passing gas, no BM since. No
chest pain, SOB, palpitations, neck pain, numbness, tingling,
weakness of arms or legs, no confusion. Currently only endorses
continued bilious nausea from not eating.
At OSH, prelim read of CT Head/Abd/Pelvis was negative (showed
intrahepatic biliary dilatation and diverticulosis). CT Neck
showed C6 fx (report not available). Labs notable for Hct 38,
guaiac negative, neg UA. Pt was briefly brady to ___ though this
spontaneously resolved.
In the ED, initial VS were: 99.9 72 176/88 18 95% RA. Per report
at BID-N patient had +C6fx and arrived in ___.
Patient found to have laceration of left eye s/p suture, ___
murmur, benign abdomen, neurologically intact. Vommiting,
received 12mg zofran PTA. Spine consulted in ED who recommended
MRI c-spine, this was performed prior to patient arrival to
floor. Also given Reglan and Ativan in ED
VS prior to transfer were: 97.8 76 135/76 14 99% 3LNC
On arrival to the floor, patient actively nauseas with vomiting
of non-bloody, grossly bilious fluid. She is neurologically
intact and oriented to person, place and time. Family at
bedside.
Past Medical History:
PMH: glaucoma, interstitial cystitis, Pneumonia
PSH: cholecystectomy, appendectomy
Social History:
___
Family History:
Migraines, heart disease (father AF, brother MI)
Physical Exam:
ADMISSION:
VITALS: 98.6 166/100 97 16 91%RA-> 94% on 1LNC
GENERAL: Nausea and vomiting during exam, in ___ J collar.
Laceration of left eye is well sutured.
HEENT: PERRL, EOMI, ecchymoses developing around lacerated left
eyebrow
NECK: no carotid bruits, no JVD, no cervical tenderness to
palpation
LUNGS: Moving air well and symmetrically CTAB
HEART: RRR, S1S2 clear and of good quality, no MRG appreciated
ABDOMEN: Soft, NT, ND, NABS, no organomegaly (guiac negative in
ED)
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3, ___ strenght bilateral UE and ___, full
sensation throughout, CN ___ grossly intact.
DISCHARGE:
VITALS: 97.8 137/71 69 16 94%ra
GENERAL: NAD, in ___ J collar. Laceration of left eye is well
sutured.
HEENT: PERRL, EOMI, ecchymoses developing around lacerated left
eyebrow; no erythema, TTP, warmth over left eye; reports
discomfort with eye movement
NECK: no carotid bruits, no JVD, no cervical tenderness to
palpation, no spine point tenderness
LUNGS: Moving air well and symmetrically CTAB
HEART: RRR, S1S2 clear, harsh ___ holosystolic murmur heard at
RUSB/LUSB with radiation to carotids
ABDOMEN: Soft, NT, ND, NABS, no organomegaly (guiac negative in
ED)
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3, ___ strenght bilateral UE and ___, full
sensation throughout, CN ___ grossly intact.
Pertinent Results:
ADMISSION:
___ 02:31AM BLOOD WBC-11.2*# RBC-4.93# Hgb-14.9# Hct-44.8#
MCV-91 MCH-30.3 MCHC-33.3 RDW-13.2 Plt ___
___ 02:31AM BLOOD Neuts-91.8* Lymphs-5.9* Monos-2.1 Eos-0
Baso-0.2
___ 02:31AM BLOOD Plt ___
___ 02:31AM BLOOD Glucose-149* UreaN-19 Creat-0.9 Na-142
K-3.7 Cl-102 HCO3-29 AnGap-15
___ 02:31AM BLOOD Calcium-8.9 Phos-4.9*# Mg-1.9
___ 03:25AM URINE Color-Straw Appear-Clear Sp ___
___ 03:25AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-TR Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 03:25AM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1
TransE-<1
___ 03:25AM URINE CastHy-1*
___ 03:25AM URINE Mucous-RARE
DISCHARGE:
___ 05:40AM BLOOD WBC-7.2 RBC-4.05* Hgb-12.3 Hct-36.6
MCV-90 MCH-30.2 MCHC-33.5 RDW-13.2 Plt ___
___ 05:40AM BLOOD Plt ___
___ 05:40AM BLOOD Glucose-89 UreaN-21* Creat-0.8 Na-139
K-3.8 Cl-105 HCO3-28 AnGap-10
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
#MRI cervical spine: 1. Although there is subtle signal seen at
the anterior margin of C6 at the site of ossicle seen on CT, it
is too small to characterize. No definite ligamentous
disruption identified or facet joint malalignment seen. No
prevertebral hematoma seen.
2. Mild degenerative changes in the cervical region.
#OSH cervical CT: THERE IS A FRACTURE IN THE ANTERIOR INFERIOR
MARGIN OF THE C6 VERTEBRAL BODY LOCATED AT THE ATTACHMENT OF THE
ANTERIOR LONGITUDINAL LIGAMENT. THIS FINDING IS CONCERNING FOR
#OSH CT head: NO EVIDENCE OF HEMORRHAGE OR MASS EFFECT. CHRONIC
FINDINGS AS DETAILED ABOVE.
#OSH CT ABD/PLV: 1. MILD INTRAHEPATIC BILIARY DUCTAL
DILATATION. 2. HEPATIC AND RENAL CYSTS. THERE ARE MULTIPLE
TINY HEPATIC AND RENAL LESIONS THAT ARE TOO SMALL TO ACCURATELY
CHARACTERIZE BY CT BUT OF DOUBTFUL CLINICAL SIGNIFICANCE. 3.
DIVERTICULOSIS.
Brief Hospital Course:
___ yo F with PMHx significant for left carotid body surgery who
presented s/p syncopal event, likely vasovagal with hypovolemic
component, found to have C6 fracture, who was discharged in
asymptomatic condition with 24h holter monitor to confirm
non-cardiac etiology of this syncopal episode.
ACTIVE ISSUES:
# Syncope: Patient presented with 1x episode of syncope
complicated by fall and LOC. History is notable for lack of
seizure or TIA/CVA symptoms. EKG without ischemic changes and
biomarkers negative. Electrolytes normal. Hct normal. Patient
was borderline orthostatic with 18 SBP drop as fluids were
administered. CT head did not show acute change. SVT as outlined
below resolved. Patient was treated with IVF with symptomatic
improvement, and was not orthostatic at discharge. Based on
history and improvement, this is considered to be a vasovagal
event coupled with hypovolemia. At time of discharge, patient
was asymptomatic and PCP ___ was discussed.
# C6 fracture: Patient was noted to have C6 fracture on imaging.
No point tenderness on exam. No focal neurological deficits were
noted. Spine Surgery evaluated patient and reccommended
maintaining ___ collar at all times for one month, based on
MRI findings, until re-evaluation at ___.
# SVT: Patient was noted to have SVT on EKG at admission.
Monitoring on tele revealed multiple runs of SVT over the first
night. She was treated with IVF and pain control, and SVTs
resolved. At time of discharge, she was SVT-free for >24h.
However, due to concern for arrhythmia, patient was discharged
with holter monitor with instructions for ___.
# Facial Laceration: Laceration sustained in fall over left
eyebrow. Sutured in ED. Sutures should be removed in ___ days.
This was communicated to the patient.
CHRONIC ISSUES:
# Glaucoma: Chronic, stable. We continued and discharged patient
on home medications.
# Cataracts: Patient was s/p surgery week prior to presentation.
We continued and discharged her on home medications.
TRANSITIONAL ISSUES:
Full Code
Suture removal ___ Holter monitor
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES ___
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
3. Polymyxin B Sul-Trimethoprim *NF* (trimethoprim-polymyxin B)
0.1-10,000 %-unit/mL ___
4. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
5. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
2. Multivitamins 1 TAB PO DAILY
3. Polymyxin B Sul-Trimethoprim *NF* (trimethoprim-polymyxin B)
0.1-10,000 %-unit/mL ___
4. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES ___
5. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
6. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet(s) by mouth three times a day
Disp #*50 Tablet Refills:*0
7. Docusate Sodium 100 mg PO BID
Patient may refuse. Hold if patient has loose stools.
RX *docusate sodium 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Senna 2 TAB PO BID:PRN constipation
Patient may refuse. Hold if patient has loose stools.
RX *senna 8.6 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
- Vasovagal syncope
Secondary
- Viral Gastroenteritis
- s/p cataract surgery
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___:
It was a pleasure taking care of you at ___
___. You were admitted because you fainted and hit
your head. You were evaluated by neurosurgeons who found a
fracture of a bone in your spine (called "C6"). You will need to
wear a neck brace for the next month for protection.
We believe your fainting episode was caused by dehydration and a
vasovagal reponse. This can happen when someone is having a
bowel movement and straining. Please make sure to drink plenty
of fluids (>1.5L per day) and eat fiber to ensure that you do
not strain with stooling. You are now ready for discharge with
a heart monitor to make sure you are not having strange heart
rhythms at home.
To have your sutures removed, please see your primary care
physician or an urgent care / ___ clinic on ___
Thank you for allowing us to participate in your care. Best
wishes in your recovery.
Followup Instructions:
___
|
10150882-DS-5 | 10,150,882 | 29,448,542 | DS | 5 | 2127-12-10 00:00:00 | 2127-12-10 11:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
right sided weakness and inability to speak
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ yo man with no known medical history
who presents with right sided weakness and aphasia. The patient
was last seen normal at 10pm the night prior. At 6AM the
morning of admission, his daughter heard Mr. ___ fall, and
when she found him he was flailing the L side of his body
(arm/leg). He could not move his R arm or leg and could not
form words to speak. An ambulance was called, and the pt was
brought to the ED where a NIHSS was ___.
Patient's family arrived to ___, and reports that pt has no
other medical comorbidities besides for a longstanding Hx of
smoking. Upon exam (w/ translation assistance from family), the
pt is alert and oriented x 3. He is able to understand and
follow all commands (two-step commands). However, the pt is
unable to form fluent sentences, and his family reports that
some of the words he is employing in Creole are contextually
incorrect. They report that it it is appearing difficult for
him to physically form words/speak.
ROS is unable to be obtained given pt's inability to answer
questions. However, through basic yes/no responses, the pt
appears to have been assymptomatic before event this morning (no
prior HA, photophobia, fever, nausea, vomiting, abdominal pain,
chest pain, respiratory distress).
Past Medical History:
none
Social History:
___
Family History:
No family history of HTN, HLD, stroke, MIs.
Physical Exam:
*Admission Exam*
T= 97.8F, BP= 166/69, HR= 69, RR= 16, SaO2= 100% on RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, and oriented to person, place, year, and
birthday. Severe aphasia, most words are either unintelligable
or contextually incorrect. Able to repeat single words in ED.
Able to follow some simple commands (open/close eyes) as well as
some complex commands (hand raising, pointing followed by
touching). Able to name watch but not other objects on stroke
card in ED. Unable to describe the cookie jar picture. Likely
dysarthria though this was difficult to formally evaluate.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm, both directly and consentually; brisk
bilaterally. R pupil irregular. No blink to threat on R,
suggesting R hemianopsia.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation diminished to light touch, pinprick on R
VII: R facial droop, with decreased activation
VIII: Hearing grossly intact
IX, X: Palate unable to visualize due to tongue in the way.
XI: head moves side to side equally but patient is unable to
understand the directions for testing SCM/trapezius.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No adventitious movements,
such as tremor, noted. No asterixis noted. R side ___, L side at
least antigravity, likely much better but patient was not
understanding directions for formal testing.
-DTRs:
Bi Tri ___ Pat Ach
L 3 2 2 3 1
R 3 2 2 3 1
- Plantar response was flexor bilaterally.
- Pectoralis Jerk was present, and Crossed Adductors are
present.
-Sensory: Diminished to light touch and pinprick in R
face/arm/leg.
-Coordination: No intention tremor, no dysmetria on L FNF.
-Gait: Unable to test.
*Discharge Exam*
T AF SBP 100-130 HR 55-60 RR 18 >97% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple
Pulmonary: Regular respirations
Abdomen: ND
Extremities: WWP
Skin: no rashes or lesions noted.
Neurologic:
MS: Oriented to person, place, date (not month). Speaks in
short phrases, non-fluent, dysarthric. Can name few objects but
trouble w/ both low/high frequency objects, repetition intact to
simple but not complex phrases, some difficulty performing
cross-body commands but can otherwise follow simple commands
well
CN: R NLF flattening, R Buccinator weakness, Emotional
volutional dissociation w/ smile, VF difficult to assess (pt
kept looking at fingers) but equal blink to threat bilaterally,
Feels temp/light touch on both sides of face, but diminished
pinprick on R face.
Motor: Full strength LUE/LLE, RUE completely flaccid,
triple-flexion R leg,
Sensory: Intact light touch and cold bilaterally but diminished
pinprick throughout on right.
Reflexes: RUE/RLE 3+, Upgoing R toe, LUE/LLE 2+, downgoing L
toe, 3 beats clonus R and 0 on L
Coordination: No intention tremor, no dysmetria on L FNF.
Gait: Unable to test ___ patient safety
(Overall notable for expressive>receptive aphasia, R
hemi-hypoesthesia, R hemiplegia with RUE flaccid and RLE triple
flexion)
Pertinent Results:
___ 06:27AM BLOOD WBC-6.0 RBC-5.00 Hgb-15.2 Hct-45.1 MCV-90
MCH-30.4 MCHC-33.7 RDW-15.3 Plt ___
___ 01:22PM BLOOD Neuts-53.7 ___ Monos-7.6 Eos-0.6
Baso-0.5
___ 01:22PM BLOOD ___ PTT-32.4 ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD ___ 06:27AM BLOOD Glucose-107* UreaN-14 Creat-1.1 Na-139
K-4.1 Cl-102 HCO3-22 AnGap-19
___ 06:01AM BLOOD ALT-37 AST-35 AlkPhos-71 TotBili-0.8
___ 06:27AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.2
___ 01:22PM BLOOD %HbA1c-5.9 eAG-123
___ 01:22PM BLOOD Triglyc-92 HDL-33 CHOL/HD-5.3 LDLcalc-125
___ 01:22PM BLOOD TSH-0.92
MRI Brain:
1. Late acute to subacute infarct of the left posterior putamen
extending
along the coronal radiata.
2. Periventricular, subcortical and pontine T2/FLAIR white
matter
hyperintensities, which are nonspecific, but commonly seen in
setting of
chronic microangiopathy.
3. Right frontal encephalomalacia unchanged from prior CT
examination.
CT/CTA:
Sequela of chronic small vessel ischemic disease and prior
infarction in the right frontal periventricular white matter,
however no evidence of acute infarction or hemorrhage.
Allowing for anatomic variation, unremarkable CTA of the head
and neck without evidence of occlusion, dissection or aneurysm.
Echo:
The left atrium is moderately dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is borderline
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Brief Hospital Course:
Assessment/Plan:
Mr. ___ is a ___ yo man with no known medical history
who presents with right sided hemianopsia, hemiplegia,
hemisensory loss, expressive>receptive aphasia and dysarthria.
CT Head did not show early ischemic signs but did show evidence
of an old R ___ infarct (which on MRI looks an
anterior R putamenal lenticulostriate stroke). CTA is clean. MRI
ultimately showed a L anterior choroidal stroke involving the
posterior putamen, posterior PLIC and likely part of the arcuate
fasciculus. He was hypertensive on admission and has one
documented BP of 150/66 one year prior but is not any
medications at home. LDL is 129. He also has a long smoking
history. Etiology given extensive white matter disease on FLAIR,
smoking history, prior lenticulostriate infarct, likely new
hypertension that has developed over the last year, and new
anterior choroidal infarct is likely atherosclerotic vascular
disease of small vessels.
Neuro:
- CT/CTA without intracranial atherosclerosis but with old R
putamenal stroke
- MRI head with evidence of L anterior choroidal stroke
involving L PLIC, L putamen and evidence of old stroke in R
putamen/PLIC
- Check risk factors: fasting lipid panel with LDL 125, TSH
0.92, and HBA1c 5.9
- ASA 81 mg daily + Atorvastatin 80 mg daily
CV:
- R/o MI with CE - trop<0.01
- Monitor by telemetry - negative for atrial fibrillation during
admission
- Initially allowed by to autoregulate but goal is now
normotension. Patient will likely require anti-HTN medications.
- Trans-thoracic echo with bubble with elongated LA 5.6 cm,
EF>55%, no ASD/PFO/Thrombus, borderline PA HTN
PULM:
- Given borderline PA HTN, lung disease from long smoking
history is possible. This should be followed up outpatient.
ENDO:
- Finger sticks QID, insulin sliding scale with normoglycemia
throughout admission
FEN:
- nectar thick / soft solids after ST eval
TOX/METAB:
- Serum tox negative, LFTs 48/41->40/33 on recheck
ID:
- UA clean
- CXR clear of overt infection
PPX:
- SQ heparin/pneumoboots
- Precautions: fall and aspiration
Collateral:
LSW at 10pm the night prior to admission. At 6AM the morning of
admission, his daughter heard Mr. ___ fall, and when she
found him he was flailing the L side of his body (arm/leg). He
could not move his R arm or leg and could not form words to
speak. An ambulance was called, and the pt was brought to the
ED where a NIHSS was ___.
Patient's family arrived to ___, and reports that pt has no
other medical comorbidities besides for a longstanding Hx of
smoking. Upon exam (w/ translation assistance from family), the
pt is alert and oriented x 3. He is able to understand and
follow all commands (two-step commands). However, the pt is
unable to form fluent sentences, and his family reports that
some of the words he is employing in ___ are contextually
incorrect. They report that it it is appearing difficult for
him to physically form words/speak.
ROS is unable to be obtained given pt's inability to answer
questions. However, through basic yes/no responses, the pt
appears to have been assymptomatic before event this morning (no
prior HA, photophobia, fever, nausea, vomiting, abdominal pain,
chest pain, respiratory distress).
PMH/SHx - notable for primarily long smoking history. Last BP
150/66 in ___ but no checks since. Sees his PCP ___.
Takes no medications.
Medications on Admission:
none
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Heparin 5000 UNIT SC TID
4. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L anterior choroidal stroke
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted with a stroke on the left side of your brain
causing difficulty speaking, difficulty seeing on the right, and
right sided weakness and numbness. You ended up have a stroke on
the L side of your brain. To prevent you from having a stroke
again, you should quit smoking, keep your cholesterol under
control, and keep your blood pressure under control.
We started you on aspirin 81 mg daily and on atorvastatin 80 mg
daily for cholesterol control and to decrease risk of future
stroke. Your blood pressure will likely require control with
medication that should be managed long term by Dr. ___.
We were able to control your blood pressures well with
hydrochlorothiazide 12.5 mg once daily while you were an
inpatient.
Followup Instructions:
___
|
10150980-DS-15 | 10,150,980 | 26,326,661 | DS | 15 | 2140-10-02 00:00:00 | 2140-10-03 07:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
?Aspiration
Major Surgical or Invasive Procedure:
None
History of Present Illness:
PCP: Dr. ___
___ year old male sent from ___ for increased coughing and
difficulty breathing after eating. Over the past couple of
months staff at nursing facility has become concerned with
aspiration with eating. Especially prominent with thin liquids.
Today pt was evaluted by PCP for aspiration and then referred to
ED for further evaluation. Pt. has hx of parkinsons and is at
mental baseline which is responsive to commands but only able to
give ___ word answers. SPO2 100% on RA. VSS.
In the ED, initial vitals were: 100.4 70 117/78 24 96% room air.
In the ED, blood cultures were obtained and a flu swab was
performed. A CXR showed atelectasis without consolidation. His
temp trended back down to normal without intervention.
On the floor, pt is comfortably sleepin in bed. ___ manager
in room with him and able to provide hx noted above.
Past Medical History:
Mental Retardation 2/t Congenital Toxo
Parkinsons Disease
R eye blindness 2/t Macular Degeneration
HTN
HLD
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T: 98.3 BP:155/84 P:98 R:20 O2:98% RA
General: no acute distress, sleeping with mouth open, AO x1
knows name
___ anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: following commands, no gross focal deficits
DISCHARGE PHYSICAL EXAM
VS: 98.3 109-138/57-70 54-66 20 96%RA
General: NAD, sleeping with mouth open, AO x1 knows name, pill
rolling tremor in R arm
___: Sclera anicteric, MMM, oropharynx clear, chronic R eye
pupil deformity
Lungs: CTAB
CV: S1S2 RRR no m/g/c/r
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Following commands, no gross focal deficits
Pertinent Results:
ADMISSION LABS
___ 05:30PM BLOOD WBC-13.5* RBC-4.42* Hgb-14.3 Hct-42.9
MCV-97 MCH-32.5* MCHC-33.5 RDW-13.6 Plt ___
___ 05:30PM BLOOD Neuts-75.7* Lymphs-12.1* Monos-7.2
Eos-4.3* Baso-0.7
___ 05:30PM BLOOD Glucose-81 UreaN-32* Creat-1.2 Na-142
K-4.0 Cl-102 HCO3-28 AnGap-16
___ 06:35AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.2
___ 05:31PM BLOOD Lactate-1.6
___ 09:00PM URINE Color-Yellow Appear-Clear Sp ___
URINE
___ 09:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
DISCHARGE LABS
___ 06:55AM BLOOD WBC-10.5 RBC-4.11* Hgb-13.5* Hct-40.1
MCV-97 MCH-32.7* MCHC-33.6 RDW-13.6 Plt ___
___ 06:55AM BLOOD Glucose-76 UreaN-24* Creat-1.1 Na-139
K-3.7 Cl-103 HCO3-27 AnGap-13
___ 06:55AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.2
MICRO
___ 6:15 pm Influenza A/B by ___
Source: Nasopharyngeal swab.
**FINAL REPORT ___
DIRECT INFLUENZA A ANTIGEN TEST (Final ___:
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final ___:
Negative for Influenza B.
Blood Cx x2 Pending w/ nothing growing
IMAGING
CXR ___
IMPRESSION:
Minimal patchy bibasilar airspace opacities likely reflect
atelectasis. No focal consolidation noted.
Swallow Study ___
Swallowing video fluoroscopy: Oropharyngeal swallowing video
fluoroscopy was performed in conjunction with the speech and
swallow division. Multiple consistencies of barium were
administered. Barium passed freely through the oropharynx
without evidence of obstruction. Deep penetration was seen with
nectar thick liquids, and aspiration was seen with thin liquids.
Impression: Penetration with nectar thick liquids and aspiration
with thin liquids.
Brief Hospital Course:
Mr. ___ is a ___ h/o mental retardation, parkinsons who
was sent to the hospital from extended care facility for
?aspiration.
# Aspiration Risk: Group home concerned about possible
aspiration with eating over the last few months. Reported to
have increasing work of breathing and coughing after meals. Seen
by PCP (initial first visit) and given these reports and an
inability to obtain a pulse oximetry, was referred to ED for
work-up. No hypoxia during admission and pt had normal lung exam
without any increase work of breathing/coughing. CXR with likely
atelectasis, and no focal condolidation. Initial bedside speech
and swallow evaluation was passed by the patient, however, given
the reports, decision was made to pursue a video swallow. Video
swallow showed clear aspiration of thin liquids. Recommendations
as below:
RECOMMENDATIONS:
1. PO diet of nectar thick liquids and ground solids
2. 1:1 supervision for al PO intake
3. Crushed meds with puree as able. Meds that cannot be crushed
can be given whole with apple sauce
4. TID oral care
5. encourage small sips of liquid by straw
6. No mixed consistencies (liquids and solids together)
7. Small sips of thin liquid water are OK between meals after
oral care to assist with hydration
8. Give Carbi-Levodopa meds ___ prior to meals in order to
help reduce aspiration risk
# Fever: Low grade fever to 100.4 with mild leukocytosis in ED
which resolved without medications. Infectious etiology is a
possibility in this non-verbal pt. Group home concerned about
aspiration with eating, CXR here did not show evidence of
consolidation. UA was negative. Pt was viral swabbed in ED, and
negative for flu. Infectious work-up was unrevealing and patient
was afebrile during admission. No antibiotics given.
# Parkinsons: Continued carbidopa/levodopa.
# HTN: Continued HCTZ and Atenolol.
# Depression / Anxiety: Continued effexor, alprazolam.
Transitional Issues:
-DNR/DNI (per facility manager)
-F/u blood cxs x2
-Diet recommendations as above
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain/fever
2. Donepezil 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atenolol 50 mg PO DAILY
5. Bacitracin Ointment 1 Appl TP TID:PRN skin lesions
6. Venlafaxine XR 225 mg PO DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours
Hold for K >5
10. Guaifenesin-Dextromethorphan 10 mL PO Q6H:PRN cough
11. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety
12. Carbidopa-Levodopa (___) 1.5 TAB PO QID
7am, 10am, 3pm, and 7pm
13. Vitamin D 400 UNIT PO 1X/WEEK (SA)
14. Simvastatin 10 mg PO DAILY
15. Docusate Sodium 100 mg PO BID
hold for loose stools, contact PCP
___:
1. Acetaminophen 650 mg PO Q6H:PRN pain/fever
2. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety
3. Aspirin 81 mg PO DAILY
4. Atenolol 50 mg PO DAILY
5. Carbidopa-Levodopa (___) 1.5 TAB PO QID
7am, 10am, 3pm, and 7pm
6. Docusate Sodium 100 mg PO BID
hold for loose stools, contact PCP
7. Donepezil 10 mg PO DAILY
8. Hydrochlorothiazide 25 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Simvastatin 10 mg PO DAILY
11. Venlafaxine XR 225 mg PO DAILY
12. Bacitracin Ointment 1 Appl TP TID:PRN skin lesions
13. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours
Hold for K >5
14. Vitamin D 400 UNIT PO 1X/WEEK (SA)
15. Fluticasone Propionate NASAL 1 SPRY NU DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Aspiration Pneumonitis
Secondary: ___ Disease, Hypertension, Mental Retardation
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane). Uses wheelchair as well.
Mental Status: AAOx1
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear ___,
It was a pleasure taking care fo you during your stay at ___.
You were admitted to the hospital for concerns that you have
been aspirating at your group home. Speech and swallow evaluated
your ability to swallow food and found you to be at risk for
aspiration. They recommended that you drink nectar thick lqiuids
and ground solids. In addition, they recommended that all meds
be crushed (if possible, if not, be given in apple sauce), one
to one supervision, and the ___ Disease related meds be
given 30 to 45 minutes before eating. Your CXR did not show
evidence of pneumonia. Your vital signs were normal during your
stay and you never had low oxygen levels.
Please keep the follow-up appointments made for you.
Followup Instructions:
___
|
10150980-DS-17 | 10,150,980 | 24,160,142 | DS | 17 | 2141-05-12 00:00:00 | 2141-05-13 06:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
agitation, possible seizures
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ yo man with PMH of congenital
toxoplasmosis with intellectual disability, ___ with
gait
difficulties and visual loss due to macular degeneration who
present with increasing agitation.
His caregivers say that he has had episodes of agitations before
that required admission to the hospital, thought to be due to
infections and aspiration and he has been on a modified diet
with
some improvement. More recently, he has had episodes of staring
and also agitation which was concerning, so outpatient EEG was
ordered but showed slowing suggestive of encephalopathy. He was
scheduled for an admission to EMU for 3 day EEG on ___.
On ___, he had a good day and had lunch as he normally
does. After dinner, he was being assisted to the bathroom. He
was
walking with his walker and there was a caregiver behind him
(how
they walk normally given his gait difficulties) when he suddenly
lost balance and fell backwards. He was caught by the caregiver
and lowered to the chair without headstrike. He was unresponsive
for ___ seconds, and did finally open his eyes but did not
respond as he normally would for another ___ minutes. After ___
minutes, he was able to sit up in the chair, get up and go to
the
bathroom. In the bathroom, he had ___ episodes of vomiting,
which
consisted of his dinner without any blood/bile. He was brought
to
ED and work up was done which showed slightly elevated lactate
at
3, Cr of 1.3 (previous Cr 1), UA, EKG, CXR and CT abdomen/pelvis
were normal. He was given IVF for presumed dehydration and
syncopal episode and discharged home.
___ morning, he had a pretty good day but throughout the
day
he began becoming more "agitated" which caregivers characterize
as his trying to sit up/get out of bed, arching his back and
yelling. He does have these episodes in the evenings
occasionally, which had been contributed to being hungry, but it
continued even after dinner, which was unusual. He did go to bed
and slept well ___ night.
However, the episodes of "agitation" continued throughout ___
with grunting noise, arching his back and throwing his head
backwards. He was also hitting himself in the face, trying to
get
out of chair and kept on saying that he wanted to go home, which
is new for him. He usually knows his name, where he lives and
the
friends that he lives with and he did not seem to know any of
these things. Given the ongoing/worsening problems, he was
brought back to ED.
For his medications - his sinemet has been decreased recently
due
to orofacial dyskinesia.
Past Medical History:
- Congenital toxoplasmosis
- mild intellectual disability
- visual loss due to macular degeneration, blind in R and
limited
vision on L
- progressive hearing loss
- HTN
- HLD
- CKD
- Depression/anxiety
- C diff colitis in ___
- ___ disease
- Aspiration
Social History:
___
Family History:
Unknown
Physical Exam:
Vitals: 98.6 90 142/70 20 99% RA
General: Awake, NAD, generally cooperative
HEENT: NC/AT
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted; scattered small scabs in lower
extremities bilaterally.
Neurologic:
- Mental Status: Alert, oriented to self but not to time/place.
Could tell me his name and answer few yes/no questions. Follows
simple commands such as "squeeze hand/open hand" and "stick out
tongue." Hypophonia which is baseline per caregiver. He has
continuous oral dyskinesia which is worse than baseline per
caregiver. (he was examined around 6pm and his last dose of
sinemet had been 3pm)
Intermittently, he would throw his head backward and arch his
back and grunt at the same time.
-Cranial Nerves:
I: Olfaction not tested.
II: Eyes closed throughout examination, but R cornea is cloudy.
L
pupil is pinpoint. Unable to test VF.
III, IV, VI: Unable to test.
V: Facial sensation intact to light touch.
VII: Difficult to test given continuous mouth movement, no
obvious droop or asymmetry in movement.
VIII: Hearing intact to voice.
IX, X: Palate elevates symmetrically.
XI: Unable to test.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, increased tone throughout. When patient is
not tensing, parkinsonian tremor is noted in bilateral hands.
Good finger grip bilaterally, able to pull me toward him with
good strength but otherwise unable to participate in strength
exam. Does lift his legs antigravity bilaterally.
-Sensory: Intact light touch/pinch throughout.
-DTRs: unable to test in arms, 2 in knees bilaterally. Plantar
response was flexor bilaterally.
-Coordination: Unable to test
-Gait: Unable to test
Discharge exam: oriented x3, hypophonic, relatively brady
kinetic. Able to lift all extremities against gravity without
drift. Mild tremor worst in left hand. Otherwise unchanged from
admission.
Pertinent Results:
___ 09:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-TR
___ 09:00PM URINE RBC-44* WBC-6* BACTERIA-FEW YEAST-NONE
EPI-0
___ 09:00PM URINE MUCOUS-RARE
___ 05:37PM COMMENTS-GREEN TOP
___ 05:37PM LACTATE-1.2
___ 05:30PM GLUCOSE-77 UREA N-25* CREAT-1.3* SODIUM-139
POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-27 ANION GAP-13
___ 05:30PM ALT(SGPT)-8 AST(SGOT)-22 ALK PHOS-91 TOT
BILI-0.4
___ 05:30PM LIPASE-36
___ 05:30PM ALBUMIN-3.6 CALCIUM-8.6 PHOSPHATE-4.5
MAGNESIUM-2.2
___ 05:30PM WBC-11.6* RBC-4.25* HGB-13.1* HCT-40.1 MCV-95
MCH-31.0 MCHC-32.7 RDW-12.9
___ 05:30PM NEUTS-81.0* LYMPHS-8.3* MONOS-7.2 EOS-2.7
BASOS-0.8
___ 05:30PM PLT COUNT-195
___ 05:30PM ___ PTT-31.7 ___
Brief Hospital Course:
Mr. ___ was admitted to the neurology service for cvEEG
and characterization of spells. His spells were found to be
related to sinemet causing dystonic reactions. There was no
seizure activity clinically or on EEG. His sinemet was reduced
to ___ TID and he was started on amantadine with improvement
in symptoms.
He was evaluated by speech and swallow who felt that there is a
high likelihood of silent aspiration with any diet but also that
he would be a poor candidate for enteral nutrition. In
discussion with the patient's legal guardian it was decided to
accept the risk of potential aspiration and continue the patient
on his current diet rather than to place a feeding tube.
He was discharged to his group home with planned neuro follow
up.
Medications on Admission:
carbidopa-levodopa ___ QID while awake
donepezil [Aricept] 10 mg daily
omeprazole 20 mg daily
potassium chloride ER 10 mEq daily
simvastatin 10 mg tablet daily
venlafaxine [Effexor XR] 225 mg daily
ASA 81 mg daily
docusate sodium 100 mg BID prn constipation
Discharge Medications:
1. Amantadine 100 MG PO DAILY
RX *amantadine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Capsule Refills:*0
2. Aspirin 81 mg PO DAILY
3. Carbidopa-Levodopa (___) 1 TAB PO TID
RX *carbidopa-levodopa 25 mg-100 mg 1 tablet(s) by mouth three
times a day Disp #*90 Tablet Refills:*0
4. Docusate Sodium (Liquid) 100 mg PO BID
5. Donepezil 10 mg PO QAM
6. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
RX *lansoprazole [Prevacid SoluTab] 30 mg 1 tablet,disintegrat,
delay rel(s) by mouth daily Disp #*30 Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
RX *polyethylene glycol 3350 17 gram/dose 17 g by mouth daily
Disp #*1 Bottle Refills:*0
8. Senna 1 TAB PO BID
RX *sennosides [senna] 8.8 mg/5 mL 8.8 mg by mouth twice a day
Disp #*1 Bottle Refills:*0
9. Simvastatin 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
___ disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear ___,
You were admitted to the Neurology Service at ___ for
characterization of your spells. These spells are NOT seizures,
but rather dystonia which is a side effect of your sinemet. We
decreased your dose of sinemet and started you on a medication
called amantadine to help with the side effects.
We made the following changes to your medications:
1) DECREASED SINEMET to 1 pill three times per day
2) STARTED AMANTADINE 100mg daily
It was a pleasure taking care of you during your hospital stay.
Please follow up as below.
Followup Instructions:
___
|
10151282-DS-14 | 10,151,282 | 22,754,987 | DS | 14 | 2168-04-02 00:00:00 | 2168-04-02 17:04:00 |
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 lower extremity pain
Major Surgical or Invasive Procedure:
___: right knee revision, right distal femoral replacement
History of Present Illness:
___ female, history of right knee replacement and femur
fracture, presenting with hardware complication. Here for
conversion to distal femoral replacement with Dr. ___.
Past Medical History:
Hyperlipidemia
Hypertension
DVT ×2 in setting of orthopedic surgery on warfarin
Right knee replacement
Right foot surgery
Chronic back pain with right foot drop
Social History:
___
Family History:
n/c
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Incision healing well with Aquacel dressing with scant
serosanguinous drainage
* Thigh full but soft
* No calf tenderness
* ___ strength
* SILT, NVI distally
* Toes warm
Brief Hospital Course:
The patient was admitted to the Orthopaedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Postoperative course was remarkable for the following:
POD #0, overnight, patient triggered for hypotension 78/52 and
was administered 500ml IV fluid bolus. BPs improved to 100/54.
POD #1, patient was given another 500ml IV fluid bolus for
hypotension ___ with report of fatigue. BPs remained soft
___. Repeat CBC in the afternoon showed 27.5. Patient was
administered 1 dose of albumin with SBPs improved to 110s.
Patient also had report of left leg numbness and left knee
buckling when getting up to commode. On exam back in bed, she
denied decreased sensation or numbness in LLE. Patient did
report calf pain in RLE. Given history of bilateral DVTs,
ultrasounds of the bilateral lower extremities were obtained.
Results showed partial compressibility of the left mid and
distal femoral vein and popliteal vein suggests partial chronic
DVT. No DVT in RLE.
POD #2, hematocrit was 25.4 and vital signs were stable. INR was
1.6 and Lovenox was discontinued. Coumadin continued to be dosed
daily based on INR. Drain was discontinued on POD#2. She had
serosanguinous drainage from her drain site and the dressing was
changed as needed. She was triggered in the afternoon for
sustaining a heart rate of 140s. She was asymptomatic and denied
chest pain or difficulty breathing. Her BP was 94/58 and she was
96% RA. An EKG was obtained which showed sinus tachycardia. We
discussed the plan with Dr. ___ and ___ advised that she
receive 1 unit of PRBCs. She was reassessed after the unit of
blood.
POD#3, patient was stable on the floor and cleared physical
therapy. Her hct increased to 25.8 and INR was stable at 1.7.
Patient received 2.5 mg PO of Coumadin prior to discharge. INR
should be monitored at rehab.
Otherwise, pain was controlled with a combination of IV and oral
pain medications. The patient received Lovenox bridge to
Coumadin daily for DVT prophylaxis starting on the morning of
POD#1. Lovenox was discontinued on POD #2. The Aquacel dressing
remained clean and intact without erythema or abnormal
drainage/saturation. The patient was seen daily by physical
therapy. Labs were checked throughout the hospital course and
repleted accordingly. At the time of discharge, the patient was
tolerating a regular diet and feeling well. The patient was
afebrile with stable vital signs. The patient's hematocrit was
acceptable and pain was adequately controlled on an oral
regimen. The operative extremity was neurovascularly intact.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity. Please use walker or 2
crutches for as long as you need. The physical therapist will
help guide you until you are safe to wean from assistive
devices.
Mrs. ___ is discharged to home with services in stable
condition.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fenofibrate 145 mg PO DAILY
2. TraZODone 50 mg PO QHS
3. Montelukast 10 mg PO DAILY
4. Simvastatin 80 mg PO QPM
5. FoLIC Acid 1 mg PO DAILY
6. Atenolol 50 mg PO DAILY
7. Ranitidine 300 mg PO QHS
8. Gabapentin 300 mg PO BID
9. Thiamine 100 mg PO DAILY
10. Allopurinol ___ mg PO BID
11. Omeprazole 40 mg PO DAILY
12. Levothyroxine Sodium 25 mcg PO DAILY
13. Warfarin Dose is Unknown PO DAILY16
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO DAILY
stop taking if having loose stools
3. Senna 8.6 mg PO BID
stop taking if having loose stools
4. ___ MD to order daily dose PO DAILY Duration: 1 Dose
5. Allopurinol ___ mg PO BID
6. Atenolol 50 mg PO DAILY
7. Fenofibrate 145 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Gabapentin 300 mg PO BID
10. Levothyroxine Sodium 25 mcg PO DAILY
11. Montelukast 10 mg PO DAILY
12. Omeprazole 40 mg PO DAILY
13. Ranitidine 300 mg PO QHS
14. Simvastatin 80 mg PO QPM
15. Thiamine 100 mg PO DAILY
16. TraZODone 50 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hardware failure right distal femur
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:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
7. SWELLING: Ice the operative joint 20 minutes at a time,
especially after activity or physical therapy. Do not place ice
directly on the skin. You may wrap the knee with an ace bandage
for added compression.
8. ANTICOAGULATION: Please continue your Coumadin to help
prevent deep vein thrombosis (blood clots). Goal INR for the
next 4 weeks is 1.8-2.2 to prevent post-op hematoma.
9. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower after surgery while wearing your aquacel
dressing, but no tub baths, swimming, or submerging your
incision until after your first checkup and cleared by your
surgeon. After the aquacel dressing is removed 7 days after your
surgery, you may leave the wound open to air. Check the wound
regularly for signs of infection such as redness or thick yellow
drainage and promptly notify your surgeon of any such findings
immediately.
10. ___ (once at home): Home ___, Aquacel removal POD#7, and
wound checks. If there are suture tags on either end of the
incision left, please cut the suture tags flush with the skin on
both sides on POD#7, when the aquacel is removed.
11. ACTIVITY: Weight bearing as tolerated on the operative
extremity. Use two crutches or a walker for as long as you need.
The physical therapist will help guide you until you are safe to
wean from assistive devices. Mobilize often. Range of motion as
tolerated. No strenuous exercise or heavy lifting until cleared.
Physical Therapy:
WBAT
ROMAT
Wean assistive devices as able
Mobilize frequently
AFO brace to chronic R foot drop
Treatments Frequency:
remove aquacel POD#7 after surgery
apply dry sterile dressing daily if needed after aquacel
dressing is removed
wound checks daily after aquacel removed
Followup Instructions:
___
|
10151713-DS-15 | 10,151,713 | 29,275,958 | DS | 15 | 2163-07-23 00:00:00 | 2163-07-23 19:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Haloperidol / Citalopram / amlodipine / chlorthalidone /
Penicillins
Attending: ___.
Chief Complaint:
Left leg pain; fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with a history of schizoaffective disorder,
CKD stage 3, asthma, Unspecified neurocognitive d/o, and
hypothyroid who presented to the emergency room for evaluation
of
left knee pain and difficulty with managing herself at home. Of
note she had a fall 3 days ago. She said she has been feeling
weak the past few days with decreased balance and pain in her
left leg with ambulation, worse in her left knee and foot. She
said she had many smaller falls and does not remember the
circumstances surrounding them. She does remember that one fall
was while getting into bed. She does not think any were when
going from sitting to standing or had any dizziness or headaches
associated with them. She states that she was seen at the
___ and at that time leg x-rays were normal. She
denies any head strike or loss of consciousness and does not
take
any blood thinning medications. She has had left leg pain for
weeks but increased difficulty with ambulation due to left leg
pain since her fall three days ago as well as decreased PO
intake.
Her outpatient psychiatrist was contacted given her psychiatric
history and he recommended admission for psychiatric evaluation.
She has not been able to go to her psychiatry appointments over
the past few weeks due to difficulty walking from her leg pain.
In the ED:
Initial vital signs were notable for:
95.5 74 101/63 16 97% RA
Exam notable for:
-None reported
Labs were notable for:
Initial labs notable for:
Sodium 136, K4.5, chloride 96, HCO3 23, BUN 54, creatinine 2.6
ALT 28, AST 45, ALP 91, T bili less than 0.2, albumin 3.8
WBC 8.7, hemoglobin 10.1, platelets 355
Serum tox negative for aspirin, EtOH, tricyclics, acetaminophen
level of 6
Urine tox negative for benzos, barbs, opiates, cocaine,
amphetamines, methadone, oxycodone
Repeat labs prior to transfer:
Sodium 135, K4.1, chloride 96, HCO3 21, BUN 36, creatinine 1.8
Troponin less than 0.01x2
Studies performed include:
EKG:
rate ___, SR, normal axis, borderline wide QRS, q waves in II,
II, aVf, no ST changes, early R wave progression
UA negative nitrites, leuks; urine culture negative
Left foot/leg X ray:
1. Nondisplaced fracture of the medial proximal left tibia,
without intra-articular extension. The appearance is suggestive
of an insufficiency fracture.
2. Re-demonstration of known chronic collapse and severe
subluxation of the left talonavicular joint, similar in
appearance since ___.
Left lower extremity CT:
Mildly impacted transverse likely insufficiency fracture of the
proximal medial tibial metaphysis. Some gas along the fracture
line may reflect vacuum phenomenon.
There is subtle curvilinear sclerosis along the distal medial
femoral metaphysis which may also represent an insufficiency
injury of indeterminate age however no discrete fracture line is
associated with the femoral finding.
CT head without contrast:
No evidence of an acute intracranial abnormality.
Patient was given:
IVF NS 1000 mL
PO/NG Docusate Sodium 100 mg
PO/NG LORazepam 1 mg
PO Omeprazole 40 mg
PO/NG QUEtiapine Fumarate 200 mg
PO Acetaminophen 1000 mg
IVF NS 500 mL
PO/NG Levothyroxine Sodium 112 mcg
PO/NG Levothyroxine Sodium
PO/NG Polyethylene Glycol 17 g
PO/NG Atenolol 25 mg
PO/NG Docusate Sodium 100 mg
PO/NG Furosemide 40 mg
PO Omeprazole 40 mg
PO/NG QUEtiapine Fumarate 25 mg
PO/NG Sodium Bicarbonate
PO/NG LORazepam .25 mg
PO/NG LORazepam .25 mg
PO/NG Docusate Sodium 100 mg
PO Omeprazole 40 mg
PO/NG LORazepam .25 mg
PO/NG QUEtiapine Fumarate 400 mg
PO/NG Sodium Bicarbonate 1300 mg
PO/NG Levothyroxine Sodium 112 mcg
PO/NG LORazepam .25 mg
PO/NG Polyethylene Glycol 17 g
PO/NG Atenolol 25 mg
PO/NG Docusate Sodium 100 mg
PO Omeprazole 40 mg
PO/NG QUEtiapine Fumarate 50 mg
PO/NG Sodium Bicarbonate 1300 mg
IV Ondansetron 4 mg
PO/NG LORazepam .25 mg
Consults:
Orthopedics: recommended CT of extremity to assess complete
length of fracture. If not extending into joint than can place
knee in immobilizer and TDWB
Psych:
"IMPRESSION:
- Schizoaffective d/o
- Unspecified neurocognitive d/o
- tibial fracture
- Chronic: Stage III chronic kidney disease, GERD, irritable
bowel, hx hyponatremia, hypothyroid
RECOMMEND:
- no indication for constant observation or ___ at this
time
- agree reasonable to treat in least restrictive environment
possible but does appear that the pt may be having difficulties
function independently given ___ findings; could also consider OT
/ home safety evaluation
- no psychiatric contraindication to rehab; if goes to rehab,
please request psychiatry consult at rehab on Page One for
continued medication management in consultation with Dr. ___
- continue quetiapine 400 mg po QHS for now given decreasing
lorazepam, but could decrease this further as needed
- decrease lorazepam to 0.25 mg QID
- consider neuropsychological testing as outpatient
- Appreciate case management guidance going forward"
___ who recommended:
-rehab once medically stable
CM who recommended:
-CM/financial services to follow as an inpatient
Vitals on transfer:
97.9 75 131/60 18 97% RA
Upon arrival to the floor, the patient feels congested. She does
think her breathing is more cumbersome and she thinks she has a
cold currently. She denies any runny nose or cough. She denies
any chest pain, fevers, headache, nausea, belly pain, or leg
numbness. She denies pain in her left leg at rest and only has
pain with ambulation.
Past Medical History:
Schizoaffective disorder
GERD
Hypothyroidism
Hyperprolactinemia
Urinary incontinence
Hepatitis
s/p Tonsillectomy
Depression/anxiety
Candidal esophagitis
Chronic hyponatremia
Labile blood pressure
Hepatitis B
Sleep apnea
Anemia
Rhinitis
Somatic symptom disorder
Social History:
___
Family History:
Mother died at age ___ with multiple strokes, MI's and CHF.
Father died age ___ of metastatic kidney cancer.
Sisters - HTN
MGM - deceased, stroke
Physical Exam:
=======================
Admission Physical Exam
=======================
VITALS: 98.3, 128/45, HR 78, RR 18, 91% RA
GENERAL: Alert and interactive. In no acute distress, slightly
slurred speech
HEENT: atraumatic. Pupils equal, round, and reactive
bilaterally,
extraocular muscles intact. Sclera anicteric and without
injection. Moist mucous membranes, without dentition.
NECK: supple. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: rhonchi throughout the lungs bilaterally, expiratory
wheezes at the right base, No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: 1+ pitting edema bilaterally. Pulses DP/Radial 2+
bilaterally. left leg in brace
SKIN: Warm. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. AOx3.
=========================
Discharge Physical Exam
=========================
VS: T98.2 BP 127/85 HR 74 RR 20 SpO2 95 Ra
GENERAL: Alert and interactive
HEENT: atraumatic. EOMI. Moist mucous membranes, without
dentition.
NECK: supple. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Diminished in right base, no wheezes/crackles/rhonchi. No
increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: 1+ pitting edema bilaterally. Pulses DP/Radial 2+
bilaterally. left leg in left knee immobilizer brace
SKIN: Warm. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. AOx3.
Pertinent Results:
================
Admission Labs
================
___ 03:10PM BLOOD WBC-8.7 RBC-3.13* Hgb-10.1* Hct-30.7*
MCV-98 MCH-32.3* MCHC-32.9 RDW-14.6 RDWSD-51.0* Plt ___
___ 03:10PM BLOOD Neuts-71.9* Lymphs-18.0* Monos-7.6
Eos-1.4 Baso-0.5 Im ___ AbsNeut-6.25* AbsLymp-1.56
AbsMono-0.66 AbsEos-0.12 AbsBaso-0.04
___ 03:10PM BLOOD Glucose-84 UreaN-54* Creat-2.6* Na-136
K-4.5 Cl-96 HCO3-23 AnGap-17
___ 03:10PM BLOOD ALT-28 AST-45* AlkPhos-91 TotBili-<0.2
___ 03:10PM BLOOD cTropnT-<0.01
___ 02:07PM BLOOD cTropnT-<0.01
___ 02:07PM BLOOD Lipase-26
___ 03:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-6*
Tricycl-NEG
===================
Imaging/Procedures
===================
___ FOOT AP,LAT & OBL LEFT
1. Nondisplaced fracture of the medial proximal left tibia,
without
intra-articular extension. The appearance is suggestive of an
insufficiency fracture.
2. Re-demonstration of known chronic collapse and severe
subluxation of the left talonavicular joint, similar in
appearance since ___.
___ TIB/FIB (AP & LAT) LEFT
1. Nondisplaced fracture of the medial proximal left tibia,
without
intra-articular extension. The appearance is suggestive of an
insufficiency fracture.
2. Re-demonstration of known chronic collapse and severe
subluxation of the left talonavicular joint, similar in
appearance since ___.
___ CT LOW EXT W/O C LEFT
Mildly impacted transverse likely insufficiency fracture of the
proximal
medial tibial metaphysis. Some gas along the fracture line may
reflect vacuum phenomenon.
There is subtle curvilinear sclerosis along the distal medial
femoral
metaphysis which may also represent an insufficiency injury of
indeterminate age however no discrete fracture line is
associated with the femoral finding.
___ CT HEAD W/O CONTRAST
No evidence of an acute intracranial abnormality.
___ FOOT AP,LAT & OBL RIGHT
Chronic posttraumatic and degenerative changes centered at the
first and
second tarsal metatarsal joints and proximal third through fifth
metatarsals. Though changes have progressed over time since
___. No superimposed acute fracture.
===============
Discharge Labs
===============
___ 06:45AM BLOOD WBC-9.3 RBC-3.05* Hgb-9.9* Hct-30.5*
MCV-100* MCH-32.5* MCHC-32.5 RDW-14.6 RDWSD-51.2* Plt ___
___ 06:45AM BLOOD Glucose-107* UreaN-30* Creat-2.2* Na-134*
K-4.2 Cl-90* HCO3-25 AnGap-19*
___ 06:45AM BLOOD Calcium-9.3 Phos-4.1 Mg-2.3
Brief Hospital Course:
========
Summary
========
___ female with a history of schizoaffective disorder,
CKD stage3, asthma, Unspecified neurocognitive d/o, and
hypothyroid who presented to the emergency room for evaluation
of
left knee pain and difficulty with managing herself at home.
Patient to be admitted for ___ evaluation, CM, and psych follow
up.
==============================
Acute Medical Issues Addressed
==============================
#Falls
#Failure to thrive at home:
Patient with falls at home unclear if due to left leg pain or
left leg fractures are result of falls. Patient with poor PO
intake and on seroquel and lorazepam at home so orthostasis
possible cause of falls. Orthostatics checked here are normal.
Head CT without acute process. ___ has evaluated patient and
recommended rehab for physical therapy and recommendations for
home services. Anticipated length of stay at rehab <30 days.
Decreased lorazepam dose per psych recs and will require close
psych follow-up to determine if needs change in dose of Seroquel
as well.
#Proximal left tibia fracture/femoral fracture:
X ray with concern for left tibia fracture and CT with likely
insufficiency fracture of the proximal medial tibial metaphysis
as well as potentially along the distal medial femoral
metaphysis. Fracture appears to be subacute. Per ortho, patient
can be taken out of knee immobilizer and is WBAT. Patient
without pain at rest but pain with ambulation. WBAT on left leg.
Vitamin D level was normal but started Vitamin D/Calcium
supplementation in setting of fractures. Will need outpatient
DEXA scan if not currently done. Follow up in ___ clinic in
___ d, appointment scheduled.
#Acute on chronic CKD
#Hyponatremia:
Creatinine 2.6 on admission. Improved after IVF. Baseline
appears to be around 1.7. Since improving with IVF and patient
had poor PO intake and Creatinine slightly worsened to 2.2,
likely pre-renal. Also with mild hyponatremia. Encouraged PO
intake and decreased PO furosemide from 40mg to 20mg daily.
Continued sodium bicarbonate 1300 mg PO BID.
#Schizoaffective disorder
#Unspecified neurocognitive disorder:
Patient seen by psychiatry in ED and carries diagnoses of
Schizoaffective d/o, Unspecified neurocognitive d/o. Per
psychiatry, no indication for full time ___.
They recommended OT/home safety evaluation as appears patient
having difficult living independently given fall. Per psych, no
psychiatric contraindication to rehab, and if goes to rehab,
will need psychiatry consult on Page One for continued
medication management in consultation with Dr. ___. Collateral
with her outpatient psychiatrist demonstrated that patient
missed 10 recent psych appointments. Per psych recs here,
decreased lorazepam to 0.25mg QID and continued quetiapine to
400mg PO QHS. Psych also recommends neuropsychological testing
as outpatient.
#Macrocytic anemia:
Hemoglobin slowly downtrending on admission but stabilized at 9.
Patient states she has had small amounts of blood in her stool
and occasional melena for years. Last EGD and colonoscopy in
___ showed a gastric ulcer and diverticulosis and was treated
with omeprazole 40mg BID. No active GI bleeding. B12 and folate
are low normal. Hemolysis labs unremarkable. Patient started on
a multivitamin here.
#Asthma:
On albuterol/ipratropium bromide at home. Patient lungs with
some upper airway noisy breathing but no wheezes now on duonebs.
Continued duonebs while inpatient but will transition to home
inhaler at discharge.
CHRONIC ISSUES:
#GERD: Per GI EGD note from ___, patient was to decrease dose
to 40mg daily 8 weeks post biopsy. H. pylori biopsy was
negative. Decreased omeprazole 40 mg PO BID to 40mg daily PRN
#Hypothyroid: Unclear if adherent to levothyroxine, TSH up to 23
on admission with low free T4. Would recommend rechecking after
rehab has been consistently giving her medication x 4 weeks and
adjusting as needed.
#Hypertension
Continued atenolol 25mg PO daily
==================
Medication Changes
==================
- Decreased lorazepam from 0.5 TID to 0.25 QID
- Decreased furosemide from 40mg to 20mg daily
- Started Vitamin D and calcium supplementation
- Started Multivitamin
====================
Transitional Issues
====================
[] Please recheck BMP on ___ and would give IVF and consider
discontinuing furosemide if continuing to worsen.
[] Consider neuropsychological testing as outpatient
[] Follow up in ___ clinic in ___ d
[] Will need outpatient DEXA scan if has not had one recently
[] Should have intermittent EKGs (weekly) to monitor QTc while
on Quetiapine (last QTc 478 on ___
[] Should follow-up with GI as outpatient to determine if needs
EGD/colonoscopy due to worsening anemia and patient report of
chronic BRBPR and melena
#CODE: Full
#CONTACT: ___, Relationship: son, Phone number:
___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen ___ mg PO Q12H:PRN Pain Fever
2. DiCYCLOmine 20 mg PO QID:PRN Cramps
3. Levothyroxine Sodium 112 mcg PO DAILY
4. Omeprazole 40 mg PO BID:PRN GERD
5. Atenolol 25 mg PO DAILY
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Lorazepam 0.5 mg PO TID
8. Polyethylene Glycol 17 g PO TID:PRN constipation
9. Furosemide 40 mg PO DAILY
10. albuterol sulfate 90 mcg/actuation inhalation QID:PRN
11. QUEtiapine Fumarate 50 mg PO TID
12. QUEtiapine Fumarate 200 mg PO QHS
13. Sodium Bicarbonate 1300 mg PO BID
Discharge Medications:
1. Calcium Carbonate 1000 mg PO DAILY
2. Vitamin D ___ UNIT PO DAILY
3. Furosemide 20 mg PO DAILY
4. LORazepam 0.25 mg PO QID
5. Omeprazole 40 mg PO DAILY:PRN GERD
6. QUEtiapine Fumarate 400 mg PO QHS
7. Acetaminophen ___ mg PO Q12H:PRN Pain Fever
8. albuterol sulfate 90 mcg/actuation inhalation QID:PRN
9. Atenolol 25 mg PO DAILY
10. DiCYCLOmine 20 mg PO QID:PRN Cramps
11. Docusate Sodium 100 mg PO BID:PRN constipation
12. Levothyroxine Sodium 112 mcg PO DAILY
13. Sodium Bicarbonate 1300 mg PO BID
Discharge Disposition:
Extended ___
Facility:
___
Discharge Diagnosis:
===================
Primary Diagnosis
===================
Left femur/tibia insufficiency fractures
===================
Secondary Diagnosis
===================
Fall secondary to orthostasis and pain
Schizoaffective disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You had a fall at home and were having left leg pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were evaluated by the bone doctors that determined ___ had
very small fractures in your left knee that do no require a cast
or surgery. They recommend that you follow-up with them in two
weeks
- Your falls at home may have been due to some of the
medications you have been taking. We spoke with your
psychiatrist who recommended decreasing some of your medications
to prevent further falls.
- You were also found to have some damage to your kidneys that
got better with IV fluids
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- We will arrange for you to be seen by a PCP at ___
Associates. It is important that if you are to transfer ___ to
HCA, you need to keep your ___ there so that your doctor can
get to know you.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10152017-DS-14 | 10,152,017 | 21,303,195 | DS | 14 | 2140-05-29 00:00:00 | 2140-06-05 16:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Crestor / Lipitor
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/PMHx CAD (AMI in ___ w/LAD stent. stenosis of RCA ___.
___ (LAD DES), DM, HTN p/w sudden onset of dull, pressure-like
substernal, ___, chest pain for several hours. Started
yesterday evening while he was driving his truck. Not alleviated
by rest. Patient reports that the discomfort is similar in
location to where he has had prior angina. He has difficulty
characterizing the pain, however, states that this pain was
different from prior MI, and more intense than before. He
reports the discomfort was accompanied by some dyspnea and
radiated to the back. He has not had any anginal symptoms since
his last PCI in ___. Denies N/V, diarrhea, fever, chills,
dizziness, diaphoresis or lightheadedness.
In the ED, initial vitals were 97.8 68 136/74 18 95%. ECG showed
no changes (per ED), troponin negative x 1. Was given 4 SL NG
with no relief in pain, and subsequently given IV morphine,
which resulted in rapid resolution of symptoms.
On the floor this AM patient denies any current chest pain. No
shortness of breath, diaphoresis, dizziness, or fatigue.
Past Medical History:
-Coronary artery disease: He suffered an anterior myocardial
infarction in ___ that was treated with an LAD stent. He
underwent a subsequent cardiac catheterization for recurrent
symptoms in ___. This showed a totally occluded RCA
that was unable to be opened percutaneously. In ___
he underwent stenting of the LAD with a drug eluting stent. Echo
in ___ showed EF 40%.
-AAA
-Diabetes
-Hypertension
-Hypercholesterolemia
-Systolic dysfunction
-Tobacco use.
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Exam:
VS- T=98 BP=137/80 HR=64 RR=20 O2 sat=96%RA
GENERAL- No acute distress. Laying in bed. Conversive and A&Ox3.
Appropriate mood/affect
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Injected conjunctiva
b/l. MMM No xanthalesma.
NECK- Supple with JVP of 5 cm.
CARDIAC- RRR. Soft S1&S2. NMRG.
LUNGS- CTAB. Distant breath sounds diffusely. Poor air flow. No
wheeze/rales/rhonchi
ABDOMEN- Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES- No c/c/e. No femoral bruits.
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES-
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
.
Discharge Exam:
Discharged on day of admission
Pertinent Results:
ADmission Labs:
___ 03:15AM BLOOD WBC-14.1* RBC-5.27 Hgb-16.2 Hct-46.5
MCV-88 MCH-30.7 MCHC-34.8 RDW-12.8 Plt ___
___ 03:15AM BLOOD Glucose-144* UreaN-18 Creat-1.1 Na-140
K-4.1 Cl-106 HCO3-24 AnGap-14
___ 10:15AM BLOOD WBC-12.3* RBC-5.35 Hgb-16.1 Hct-48.4
MCV-90 MCH-30.1 MCHC-33.3 RDW-12.8 Plt ___
___ 10:15AM BLOOD Glucose-120* UreaN-17 Creat-1.1 Na-142
K-4.3 Cl-105 HCO3-27 AnGap-14
.
Pertinent Labs:
___ 03:15AM BLOOD cTropnT-<0.01
___ 10:15AM BLOOD CK-MB-4 cTropnT-<0.01
.
Studies:
___ Stress Echo:
The patient exercised for 10 minutes 25 seconds according to a
___ protocol ___ METS) reaching a peak heart rate
of 110 bpm and a peak blood pressure of 166/60 mmHg. The test
was stopped because of fatigue. This level of exercise
represents a good exercise tolerance for age. In response to
stress, the ECG showed no diagnostic ST-T wave changes (see
exercise report for details). The blood pressure response to
exercise was normal. There was a blunted heart rate response to
stress [beta blockade].
Resting images were acquired at a heart rate of 56 bpm and a
blood pressure of 106/60 mmHg. These demonstrated regional left
ventricular systolic dysfunction with apical aneurysm/mild
dyskinesis and severe hypokinesis/akinesis of the distal septum,
anterior and inferior walls. The remaining segments contracted
wel (LVEF = 35-40 %). Right ventricular free wall motion is
normal. There is no pericardial effusion. Doppler demonstrated
no aortic stenosis, aortic regurgitation or significant mitral
regurgitation or resting LVOT gradient.
Echo images were acquired within 57 seconds after peak stress at
heart rates of 92 - 76 bpm. These demonstrated no new regional
wall motion abnormalities. Baseline abnormalities persist with
appropriate augmentation of other segments. There was
augmentation of right ventricular free wall motion.
IMPRESSION: Good functional exercise capacity. Non-specific ECG
changes with 2D echocardiographic evidence of prior myocardial
infarction (mid-LAD distribution) without inducible ischemia to
achieved workload. Blunted heart rate response to physiologic
stress.
.
___ CXR:
Hyperexpanded lungs with increased left lower lobe peribronchial
opacities, possible interval aspiration.
Brief Hospital Course:
___ yo M with PMH significant for CAD s/p AMI with multiple DES
and last PCI in ___. Has been chest pain free since this last
procedure. Had episode of ___ chest pain at rest yesterday
evening that lasted for several hours, and eventually resolved
with IV morphine. No EKG changes or cardiac enzyme elevation to
suggest ACS.
.
Active Issues:
#Chest pain: Ruled out for MI. Pt admitted for substernal chest
pain that radiated to his back at rest. Not similiar to prior
angina or heart attack. Pain lasted for hours and was not
alleviated by nitrolgycerin, however, did abate with IV
morphine. CXR negative for mediastinal enlargement and pt was
normotenisve throughout hospital stay, so dissection not likely.
Cardiac enzymes were negative x3, and there were no EKG changes.
Stress echo negative for any new wall motion abnormalities or
anginal symptoms. Likely that symptoms were musculoskeletal vs.
GI in nature. They did not return prior to discharge. Pt was
sent home with instructions to call Cardiology Heart Line if
symptoms return.
.
Chronic Issues
#CAD: See above. H/o AMI s/p multiple stents, the last of which
was in ___. Has remained symptom free since last cath until
last night. Character, duration, and lack of associated symptoms
made CAD less likely. Continued on home ASA, BB, ACEI, plavix,
and statin.
.
#Chronic sCHF: Last LVEF 35-40%. Stable and euvolemic on exam.
No change in repeat stres echo (see above). Continued ACEI and
BB
.
#HTN: Continued home meds
.
#NIDDM: Started on SSI in house, but d/c'ed on Metformin.
.
#HLD: Continue home meds
.
Transitional Issues:
#Unable to schedule f/u appointment w/cardiologist, Dr. ___.
Pt given number to follow-up
Medications on Admission:
CLOPIDOGREL [PLAVIX] - Plavix 75 mg tablet. 1 Tablet(s) by mouth
once a day
ECASA - 325 . ONE BY MOUTH EVERY DAY
ENALAPRIL MALEATE - enalapril maleate 10 mg tablet. 1 tablet in
the morning and 1.5 tablets in the evening - (Prescribed by
Other Provider)
ISOSORBIDE MONONITRATE - isosorbide mononitrate ER 30 mg
tablet,extended release 24 hr. 1 Tablet(s) by mouth once a day -
(Prescribed by Other Provider: Dr. ___
METFORMIN - metformin 850 mg tablet. 1 Tablet(s) by mouth three
times a day - (Prescribed by Other Provider) (Not Taking as
Prescribed: notes takes ___ times daily while working, but 3
times daily on weekends)
METOPROLOL SUCCINATE - metoprolol succinate ER 50 mg
tablet,extended release 24 hr. 1 Tablet(s) by mouth once a day
PITAVASTATIN [LIVALO] - Livalo 4 mg tablet. 1 Tablet(s) by mouth
once a day
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
2. Enalapril Maleate 10 mg PO DAILY
3. Enteric Coated Aspirin *NF* (aspirin) 325 mg Oral daily
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
5. pitavastatin *NF* 4 mg Oral daily Reason for Ordering: Wish
to maintain preadmission medication while hospitalized, as there
is no acceptable substitute drug product available on formulary.
6. Metoprolol Succinate XL 50 mg PO DAILY
7. MetFORMIN (Glucophage) 850 mg PO TID
1. Clopidogrel 75 mg PO DAILY
2. Enalapril Maleate 10 mg PO DAILY
3. Enteric Coated Aspirin *NF* (aspirin) 325 mg Oral daily
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
5. pitavastatin *NF* 4 mg Oral daily Reason for Ordering: Wish
to maintain preadmission medication while hospitalized, as there
is no acceptable substitute drug product available on formulary.
6. Metoprolol Succinate XL 50 mg PO DAILY
7. MetFORMIN (Glucophage) 850 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
chest pain
Secondary diagnosis:
coronary artery disease
chronic systolic congestive heart failure
hypertension
hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at ___. You were admitted
because you had chest pain that was concerning for a heart
attack. We looked at your heart's rhythm (electrocardiogram) and
determined that there were no changes from your prior study. We
also checked blood levels of chemicals that can sometimes be
elevated in heart attacks. You did not have any increase in
these chemicals.
You underwent a stress test that helps to decide whether or not
you will get a cardiac catheterization. There was no abnormality
on the stress test, and the probability that your chest pain is
due to your heart is very low. You do not need a catheterization
at this point.
There were no medication changes made during this admission
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
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