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name unit no admission date discharge date date of birth sex f service medicine allergies penicillins sulfa sulfonamide antibiotics tylenol tetracyclines attending chief complaint chronic nausea vomiting diarrhea of unclear etiology that failed outpatient management major surgical or invasive procedure colonoscopy history of present illness ms is a year old lady with history of liver cirrhosis alcohol use and hepatitis c s p treatment followed by dr breast cancer in in remission depression vertebral compression fractures presenting for worsening of chronic loss of appetite nausea vomiting diarrhea weight loss of unclear etiology that have failed outpatient management patient presents with her friend hcp who helped with history symptoms started in with decreased appetite says she would not finish her meal and would take leftovers home which was not typical of her at that time patient started experiencing vomiting and diarrhea diarrhea started as loose stool and progressed into diarrhea around describes her stool as yellow green color that is oily and floats bowel movements a day patient reports accidents of fecal incontinence and that s why she wears diapers now in regards to her vomiting per patient cannot keep food down initially used to vomit times a day and now she vomits whenever she eats vomitus is usually food material patient denies presyncope syncope falling or decreased urine output patient smokes marijuana once a week takes oxycodone and gabapentin for chronic pain she is also on abilify and venlafaxine for depression patient s weight dropped from almost lbs in to lbs this month 25lbs weight loss in months denies fevers shortness of breath history of recent travel hematochezia melena or contact with sick person states she has been completely sober since and is not using iv drugs since regarding her months of diarrhea that may be steatorrhea review of her records revealed that chronic pancreatitis had appeared on her list of diagnoses near the end of however patient denies ever receiving a diagnosis of acute or chronic pancreatitis ct abdomen and pelvis in without evidence of chronic pancreatitis also mri from did not show evidence of pancreatic pathology regarding her cyclical vomiting syndrome patient never experienced dizziness presyncope or syncope ct scan from did not show evidence of obstruction or malignancy patient denies dysphagia to solids or liquids uses marijuana smokes eats as brownies 2x week patient had several recent visits for the same complaints including ed on clinic on and urgent care on egd was done on scheduled from the ed visit which showed gastritis without esophageal varices patient tested positive for h pylori did not start treatment because pt saw that tetracycline had been prescribed and she refused to take because of hx of hearing loss ototoxicity when she took it in past pt tried reaching out to gi clinic to see if there was an alternative regimen but never heard back during clinic visit plan was to send stool studies to work up her steatorrhea however patient did not deliver stool samples as she is not making stool because she is not eating was prescribed zofran and compazine for her vomited of which she reported later that compazine helped her more than the zofran following clinic visit pt s hcp friend called and reported that he was concerned as she was not eating drinking and becoming weaker and dizzy patient advised to go to nearest ed for rehydration pt refused to go to ed unless she knew she would be admitted and so presented to urgent care instead at urgent care she received a liter of fluids but didn t feel any better pcp arranged for gi referral dr for functional study for gastroparesis gastric emptying study has appt with him on on the floor patient feels fatigued weak but is able to converse and ambulate normally accompanied by her hcp friend still having intermittent n v though this has improved has not had a bowel movement since weeks ago only passing gas has become able to tolerate po liquids as of a few days ago hasn t used marijuana since about weeks ago for all of her medications she had either been taking them for many years or they were started well after her symptoms started notes she s also been having stomach pain cramping that started in complete ros obtained and is otherwise negative past medical history pph outpatient psychiatrist dr being treated for alcohol dependence and mood disorder with effexor xr abilify and trazodone pmh hepatitis c cirrhosis due to alcohol abuse and hepatitis c recently diagnosed breast cancer s p lumpectomy currently undergooing xrt asthma social history family history mother reported cad with first event at age second event in also with h o dm father with cad at age family psychiatric history no history of suicide substance abuse or major mental illness physical exam admission exam vitals t po bp l sitting hr rr o2 ra gen nad cardiac tachycardic reg rhythm no mrg lungs normal wob ctab abd soft nt nd normoactive bowel sounds ext no neurologic aaox3 cn2 grossly intact moves all extremities discharge exam vitals temp po bp l lying hr rr o2 sat o2 delivery ra gen nad heent normocephalic atraumatic perla 2cm erythematous non blanching non raised well circimsucribed rash adjacent to l nasolabial fold very mild acneiform eruption on cheeks cardiac tachycardic reg rhythm no mrg lungs normal wob ctab abd soft nt nd normoactive bowel sounds ext no neurologic aaox3 cn2 grossly intact moves all extremities pertinent results admission 00pm ptt 00pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 00pm ttg iga 00pm iga 00pm calcium phosphate magnesium 00pm alt sgpt ast sgot alk phos tot bili 00pm glucose urea n creat sodium potassium chloride total co2 anion gap discharge 50am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 42am blood glucose urean creat na k cl hco3 angap 53am blood alt ast alkphos totbili 42am blood calcium phos mg 53am blood tsh 00pm blood 25vitd 56am blood cortsol 53am blood crp prealbumin zinc and copper normal microbiology am stool consistency formed cyclospora stain final no cyclospora seen microsporidia stain pending cryptosporidium giardia final no cryptosporidium or giardia seen ova parasites final no ova and parasites seen this test does not reliably detect cryptosporidium cyclospora or microsporidium while most cases of giardia are detected by routine o p the giardia antigen test may enhance detection when organisms are rare fecal culture final no salmonella or shigella found campylobacter culture final no campylobacter found fecal culture r o e coli h7 final no e coli o157 h7 found fecal culture r o yersinia final no yersinia found fecal culture r o vibrio final no vibrio found alpha antitrypsin feces test result reference range units alpha antitrypsin feces mg dl this test was performed at comment source stool calprotectin stool test result reference range units calprotectin stool mcg g mcg g normal mcg g borderline mcg g abnormal calprotectin in crohn s disease and ulcerative colitis can be five to several thousand times above the reference population mcg g or less levels are usually mcg g or less in healthy patients and with irritable bowel syndrome repeat testing in weeks is suggested for borderline values this test was performed at comment source stool pancreatic elastase stool test result reference range units pancreatic elastase l mcg g adult and pediatric reference ranges for pancreatic elastase normal mcg g moderate pancreatic insufficiency mcg g severe pancreatic insufficiency mcg g elastase e assay results are expressed in mcg g which represent mcg e1 g feces it is not necessary to interrupt enzyme substitution therapy this test was performed at comment source stool test result reference range units potassium feces meq l reference ranges have not been established however fecal osmotic gap in mosm kg can be calculated using the following equation fecal osmotic gap 2x na k a fecal osmotic gap of mosm kg or greater is indicative of osmotic diarrhea whereas a result of mosm kg or less indicates a secretory diarrhea this test was performed at comment source stool fecal fat total quantitative timed results pending gastric emptying study findings residual tracer activity in the stomach is as follows at hours of the ingested activity remains in the stomach at hours of the ingested activity remains in the stomach at hours of the ingested activity remains in the stomach there is rapid emptying for the duration of the study impression no evidence of abnormal gastric emptying of note the patient experienced symptoms throughout the course of the study additionally the patient did not consume the entirety of the standardized meal and therefore comparison to normal values should be made with caution ct head findings there is no evidence of infarction hemorrhage edema or mass effect the ventricles and sulci are normal in size and configuration plate fixation of prior right maxillary frontal and lateral wall fractures are partially visualized surgical screws are also noted over the right zygoma the visualized portion of the paranasal sinuses mastoid air cells and middle ear cavities are clear the visualized portion of the orbits are unremarkable brief hospital course ms is a year old lady with history of liver cirrhosis alcohol use and hepatitis c s p treatment breast cancer in in remission depression vertebral compression fractures presenting for worsening of chronic loss of appetite nausea vomiting diarrhea weight loss of unclear etiology that has failed outpatient management acute issues chronic diarrhea nausea vomiting poor po intake weight loss failure to thrive severe protein calorie malnutrition patient reported several months of diarrhea which she said would float at times she states she has also lost over pounds since patient has also had chronic vomiting which has worsened over the last few weeks she stated that it had been occurring with liquids and solids and it would occur just seconds to minutes after starting to eat does smoke marijuana but not daily and vomiting not associated with use cyclical vomiting less likely given her history of chronic alcohol use and mild epigastric tenderness pancreatic dysfunction was thought to be a possibility her recent mri liver and ct abdomen pelvis showed no signs of acute or chronic pancreatitis although this does not rule out exocrine pancreatic insufficiency her egd on had normal biopsies and no structural abnormalities but positive for h pylori imaging and egd with no abnormal masses making gist vipoma carcinoid tumor less likely gi was consulted recommended the following studies stool studies showed negative o p culture elastase calprotectin and alpha antitrypsin were low but per gi not diagnostic of epi given her very poor po intake precding this stool k and na suggested mixed secretory osmotic diarrhea which could also be in carbohydrate malabsorption fecal fat was pending at time of discharge vitamin d was normal although she is on supplementation for osteoporosis anti ttg iga was not elevated and total iga was normal so less likely celiac hiv antibodies were negative tsh was normal ct head showed no acute intracranial pathology she had a colonoscopy on which showed a few benign appearing sessile polyps which were biopsied she had a gastric emptying study which showed no evidence of gastroperisis her crp was mildly elevated at making an acute flair of ibd less likely she also denied any bloody diarrhea or focal pain in the llq she has a history of one oral lesion which is most likely related to her dentures from a nutrition standpoint her prealbumin was low at zinc was low likely falsely low in the setting of high crp and copper was normal her weight on admission was and she says her baseline a few months ago is her weight on the day of discharge was nutrition consulted for management of her nausea she was given compazine for nausea control prior to meals reglan was added standing in addition and she was able to tolerate good po intake by day of discharge with discharge weight despite her history of diarrhea patient developed constipation during admission possibly contributing to her nausea and abd pain increased bowel reg and had bms by day of discharge she still endorsed nausea and abd pain at discharge she was treated for h pylori gastritis as below she should have outpatient breath testing for h pylori eradication and sibo breath testing with gi for follow up h pylori gastritis patient had an egd on which demonstrated gastritis and biopsy evidence of h pylori this could contribute to her nausea and vomiting and abdominal pain based on these findings she was initially recommended bismuth quadruple therapy however the patient reported an adverse effect of hearing loss secondary to prior tetracycline use additionally she reports a history of anaphylaxis to penicillin and sulfa drug use in the past she was started on a two week course of triple therapy with with metronidazole 500mg tid clarithromycin bid and pantoprazole 40mg bid d1 of antibiotics she was also instructed to avoid nsaid use to prevent worsening of her gastritis and her home celecoxib for back pain was discontinued tachycardia pt had a persistently elevated heart rate throughout her admission in the s it would decrease slightly to fluid bolus or valvsalva maneuvers ekgs showed no signs of atrial arrhythmia and appeared to be sinus tachycardia telemetry showed mostly sinus tachycardia with one short possible asymptomatic bout of svt she received electrolyte repletion and no further arrhythmias were seen on telemetry she did not exhibit any infectious symptoms per her friend she has had a fast heart for years pt denies prior cardiac dysfunction says she can feel her heart race sometimes but denies any chest pain outside records show her hr has fluctuated b w on clinic visits she should have a follow up ekg done at her next primary care appointment headache pt had r sided headache with photophobia and nausea on night of she described it as a and denied it being the worst headache of her life her neuro exam at that time was non focal this was thought to be most consistent with a migraine her headache resolved with compazine and oxycodone she had a head ct performed earlier in her admission per above which did not show any obvious underlying causes of possible mass effect her neuro exam remained non focal throughout her admission she denied a history of migraines and possible triggers for this episode could be her acute illness new medication metronidazole and clarithromycin although not common causes of migraines in terms of management if this recurs she should avoid nsaids due to her gastritis and the patient states she has an allergy to tylenol which she reports as an episode of acute severe pain after trying tylenol she can try caffeine in the future and should follow up with her primary care if this continues to be an issue rash on patient endorsed a new itchy rash she had a 2cm erythematous non raised well circumscribed non blanching itch rash on the left nasloabial fold with very mild small acneiform papules on her cheeks no signs of anaphylaxis and no rash seen on other areas of skin itchiness responded to benadryl and rash improved with topical steroids chronic issues cirrhosis likely compensated patient has a history of cirrhosis thought to be secondary to a combination of chronic alcohol use and hepatitis c the patient reports discontinuing alcohol since and she has been treated for her hcv in hcv genotype treated with daa with good response in reducing her viral load her most recent mri of her liver and ct abdomen pelvis show no mention of ascites her most recent egd on was negative for varices she should continue to follow with her gi team depression insomnia anxiety her home abilify venlafaxine mirtazapine lorazepam and diphenhydramine were continued throughout her admission breast cancer she has a history of er pr her2 breast cancer which was resected in and treated with hormonal risk reduction with anastrozole lupron for years this was then complicated by osteoporosis and compression fractures in t4 t12 and l1 seen in her last breast mri was in which was unremarkable she should continue to follow with her oncologists and stay up to date with her breast cancer screening chronic back pain from vertebral compression fractures patient has a history of t4 t12 and l1 vertebral compression fractures thought to be secondary to hormonal risk reduction therapy following resection of her breast cancer she is written for oxycodone q6 prn as her home dose although the patient states she usually takes it while home to manage pain she continued her home gabapentin during her stay her celcoxib was discontinued due to concern for possible worsening of her gastritis she was also given lidocaine topical patches for pain control htn her home amlodipine was continued throughout admission asthma her home albuterol inhaler was available to her but sparingly used throughout her admission transitional issues discharge weight lbs discharge qtc f u colonoscopy biopsies and repeat colonoscopy in years pending biopsy results f u pending fecal fat studies triple therapy for week course through then continue pantoprazole for at least weeks for gastritis f u for h pylori eradication in months consider outpatient sibo breath testing vs empiric rifaximin has gi follow up continue to monitor ecgs at outpatient follow up given many qtc prolonging meds qtc on day of discharge she should avoid nsaid use to prevent worsening of her gastritis including her home celecoxib this may require re optimization of her pain control for her spinal compression fractures f u polyp histology in need f u colonoscopy in years pending pathology results continue to recommend avoidance of marijuana patient amphetamine dextroamphetamine mg po bid held for duration of admission and on discharge no notable effects from withholding consider resuming as outpatient if indicated she should have a f u ekg to monitor her tachycardia and screen for qt prolongation at her next pcp code fc presumed contact name of health care proxy relationship friend phone on admission the preadmission medication list is accurate and complete amphetamine dextroamphetamine mg po bid mirtazapine mg po qhs lorazepam mg po bid prn anxiety aripiprazole mg po qam venlafaxine xr mg po daily oxycodone immediate release mg po q6h prn pain moderate diphenhydramine mg po tid prn anxiety insomnia amlodipine mg po hs celecoxib mg oral bid prn back pain from compression fractures gabapentin mg po tid prochlorperazine mg po tid prn nausea vomiting first line albuterol inhaler puff ih q4h prn wheezing discharge medications clarithromycin mg po q12h duration weeks rx clarithromycin mg tablet s by mouth twice a day disp tablet refills docusate sodium mg po bid rx docusate sodium colace mg capsule s by mouth twice a day disp capsule refills hydrocortisone cream appl tp qid prn facial rash metoclopramide mg po tid rx metoclopramide hcl mg tablet by mouth three times a day disp tablet refills metronidazole mg po tid duration weeks rx metronidazole flagyl mg tablet s by mouth three times a day disp tablet refills multivitamins w minerals tab po daily rx multivitamin tx minerals tablet s by mouth once a day disp tablet refills pantoprazole mg po q12h rx pantoprazole mg tablet s by mouth twice a day disp tablet refills polyethylene glycol g po daily rx polyethylene glycol gram dose grams by mouth once a day refills senna mg po bid prn constipation first line rx sennosides senna mg tablet by mouth twice a day disp tablet refills albuterol inhaler puff ih q4h prn wheezing amlodipine mg po hs aripiprazole mg po qam diphenhydramine mg po tid prn anxiety insomnia gabapentin mg po tid lorazepam mg po bid prn anxiety mirtazapine mg po qhs oxycodone immediate release mg po q6h prn pain moderate prochlorperazine mg po tid prn nausea vomiting first line venlafaxine xr mg po daily held amphetamine dextroamphetamine mg po bid this medication was held do not restart amphetamine dextroamphetamine until you see your pcp home discharge diagnosis primary diagnosis failure to thrive h pylori gastritis chronic diarrhea secondary diagnosis atrial tachycardia headache chronic back pain discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions discharge instructions dear ms it was a pleasure caring for you at why was i in the hospital you came to the hospital because you had trouble eating and keeping your food down what happened to me in the hospital you were given fluids and anti nausea medicine to help you eat you had a colonoscopy which showed a few benign polyps not cancerous appearing and the confirmatory biopsy results will be sent to you when they are available your gastric emptying study showed no signs of delayed gastric emptying you were started on two antibiotics for your h pylori infection what should i do after i leave the hospital continue to take all your medicines and keep your appointments continue to take your anti nausea meds prior to meals to help you to eat more please avoid all marijuana as this may contribute to your symptoms we wish you the best sincerely your team followup instructions

name unit no admission date discharge date date of birth sex f service neurology allergies no known allergies adverse drug reactions attending chief complaint seizure major surgical or invasive procedure none history of present illness the patient is a right handed woman with a history of complex partial seizures was brought to the ed by ems due to concern for seizure at home she reports that her father passed away weeks ago after a fairly lengthy illness this is caused her a great deal of stress and other social difficulties since that time she has been having several episodes per day which are of a new semiology for her she describes these as follows a feeling of swelling and numbness of the tongue which is accompanied by difficulty forming words she feels that she is able to think of the words she wants to say but is unable to get her mouth to produce them she is able to understand people if they did speak to her she feels quite certain that the tongue numbness swelling as well as the difficulty speaking come on at the same time episodes last between and minutes after which she is completely back to normal her husband has apparently seen his episodes and there is no associated abnormal eye movements oral or facial automatism or abnormal movement of the limbs she has had the episodes while seated and has been able to maintain her posture she is unsure if she is ever had them while standing these episodes have been happening between and times per day for the last weeks she is unable to identify any particular triggers and feels that they come on randomly these episodes actually started at rehab where she has been for the last several days after she tripped and fell and sustained a left ankle injury at home other than this there have not been any recent changes to her medical status she is not certain of the medicine she takes but denies any changes in the doses or frequency of her antiseizure medications her medications are currently administered by visiting nurse she reports that she was not sleeping very well at rehab but denies any significant loss of sleep she also denies any recent infections fevers etc today her visiting nurse apparently noted her to have one or more of these episodes and recommended she be brought to the ed for evaluation regarding her seizure history she has been followed by dr quite some time seizure started in the her typical semiology consists of a visual aura of flashing lights followed by a head deviation to the right lasting a minute or so this is been followed by a postictal cry as well as difficulty speaking for several minutes apparently there also sometimes strange behaviors such as starting to make a pot of coffee she has never had a generalized seizure prior medications include dilantin which was stopped for unclear reasons she is currently on a regimen of levetiracetam phenobarbital and lamotrigine which she reports she tolerates well she feels like her last seizure was around years ago on neurologic review of systems the patient denies headache lightheadedness or confusion denies loss of vision blurred vision diplopia vertigo tinnitus hearing difficulty dysarthria or dysphagia denies focal muscle weakness numbness parasthesia denies loss of sensation denies bowel or bladder incontinence or retention denies difficulty with gait on general review of systems the pt denies recent fever or chills no night sweats or recent weight loss or gain denies cough shortness of breath denies chest pain or tightness palpitations denies nausea vomiting diarrhea constipation or abdominal pain no recent change in bowel or bladder habits no dysuria denies arthralgias or myalgias denies rash past medical history copd epilepsy complex partial followed by dr seizures characterized by head turn to the right with impaired ability to speak but maintains awareness this lasts for minutes followed by emotional crying and then headache and nausea last seizure was years ago avm left frontal s p proton beam radiation at in and again pcom aneurysm s p clipping at in hld lumbar disc herniation presented with left sciatic pain but none recently anemia iron deficiency eosinophilia social history family history no family history of neurologic disease both parents had copd father had colon cancer physical exam admission physical examination vitals t p r bp sao2 room air general awake cooperative nad heent nc at no scleral icterus noted mmm no lesions noted in oropharynx neck supple no carotid bruits appreciated no nuchal rigidity pulmonary breathing comfortably on room air cardiac rrr nl s1s2 no m r g noted abdomen soft nt nd extremities no edema skin no rashes or lesions noted neurologic mental status alert oriented x able to relate history without difficulty spells world backward as dlow language is fluent with intact repetition and comprehension normal prosody there were no paraphasic errors pt was able to name both high and low frequency objects able to follow both midline and appendicular commands there was no evidence of apraxia or neglect cranial nerves ii iii iv vi perrl to 2mm and brisk 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 ip quad ham ta gastroc l r sensory there is a circumferential length dependent loss of pinprick and temperature sensation below the upper shin no extinction to dss dtrs bi tri pat ach l r plantar response was mute bilaterally coordination no intention tremor no dysdiadochokinesia noted no dysmetria on finger to nose bilaterally gait not tested discharge physical exam hr data last updated temp tm bp hr rr o2 sat o2 delivery l general elderly woman lying comfortably in recliner nad heent nc at eeg leads in place cardiac warm well perfused pulmonary no increased work of breathing abdomen soft nd extremities wwp cam boot on lle skin no rashes or lesions noted neurologic mental status awake alert oriented to self date able to relate history without difficulty attentive to interview speech is fluent with full sentences intact repetition and intact verbal comprehension naming intact no paraphasias no dysarthria normal prosody no evidence of hemineglect no left right confusion able to follow both midline and appendicular commands cranial nerves perrl brisk eomi no nystagmus v1 v3 without deficits to light touch bilaterally no facial movement asymmetry hearing intact to voice trapezius strength bilaterally tongue midline motor normal bulk and tone no drift no tremor or asterixis delt bic tri ecr fex ip quad ham ta gas l r l wrapped in dressing in cam boot sensory no deficits to light touch bilaterally reflexes deferred coordination no dysmetria with finger to nose testing bilaterally gait unable to assess pertinent results admission labs 59pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 59pm blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 45pm blood ptt 59pm blood glucose urean creat na k cl hco3 angap 59pm blood alt ast alkphos totbili 59pm blood calcium phos mg discharge labs 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood ptt 39am blood glucose urean creat na k cl hco3 angap 39am blood calcium phos mg 05am blood caltibc ferritn trf 59pm blood phenoba cxr ap lat findings no focal consolidation is seen there is minimal basilar atelectasis left upper hemithorax scarring is noted there is mild pulmonary vascular congestion no pleural effusion or pneumothorax is seen cardiac silhouette as mildly enlarged there is mild prominence the main pulmonary artery would suggest a component of underlying pulmonary hypertension impression mild pulmonary vascular congestion mild prominence of the main pulmonary artery suggest component of underlying pulmonary hypertension cta head neck impression no evidence of acute infarction or intracranial hemorrhage stable large left frontal avm with arterial feeders from the left mca and venous drainage into the superior sagittal sinus approximately stenosis by nascet criteria of the proximal bilateral internal carotid arteries mild to moderate multifocal atherosclerotic calcifications of the head and neck vasculature with no evidence of occlusion tib fib ap and lat left impression diffuse osteopenia is noted there is a healing subacute spiral fracture through the distal tibial metadiaphysis which demonstrates fibroosseous bridging and callus formation there is a healed fracture through the distal fibular diaphysis multiple well corticated ossific densities inferior to the medial malleolus most likely represent sequela from remote trauma there are mild degenerative changes of the medial patellofemoral compartment and tibiotalar joint foot ap lat obl left port findings diffuse osteopenia is noted no acute fracture or dislocation is seen there are sclerotic changes along the second third and fourth metatarsal necks which most likely represent subacute chronic fractures mild degenerative changes are seen in the hindfoot and midfoot there is a small plantar calcaneal spur there is a small skin defect along the posterior aspect of the calcaneus there is no adjacent cortical erosion focal osteopenia or periosteal reaction impression small skin defect along the posterior aspect of the calcaneus no radiographic evidence of osteomyelitis if there is high clinical concern for osteomyelitis further evaluation may be performed with mri with contrast or nuclear medicine bone scan sclerotic changes along the second third and fourth metatarsal necks which most likely represent subacute chronic fractures please see separate report from concurrently performed radiographs of the left tibia and fibula for additional findings brief hospital course ms is a woman with a history of epilepsy was well controlled on levetiracetam lamotrigine phenobarbital who presented with new onset of episodes of tongue numbness swelling sensation as well as aphasia eeg shows multiple left frontal brief seizures long patient may be having breakthrough seizures due to uti and soft tissue infections she also has a l heel ulcer and a r groin abscess s p i d by acs epilepsy cveeg monitoring showed numerous of electrographic seizures daily did not improve on addition of ativan bridge vimpat klonopin however there was decrease in clinical seizures on fycompa 6mg such that there were no further clinical events x24 hours prior to discharge continued home aeds lev 1000mg bid phb 2mg bid ltg 200mg tid vimpat 250mg bid started ineffective weaned off trialed ativan bridge which was not improving eeg so it was stopped after days stopped klonopin on after short ineffective trial prednisone mg on mg on mg back to home dose of mg daily on per outpatient epileptologist dr started fycompa at mg qhs and uptitrated to mg qhs plan to increase to 8mg qhs in week as outpatient r groin abscess with purulent drainage consulted acs s p i d doxycycline and keflex on to complete day course bid wet to dry dressing changes per acs heel ulcer r buttock ulcer wound care consulted podiatry consulted please see wound recs multiple l tibia fibula fractures subacute in x ray shows multiple subacute healing fractures spoke with patient s outpatient ortho dr weight bearing as tolerated if cam boot in place with walker per op ortho consulted recommended rehab uti urine culture grew e coli resistent to cipro and ampicillin sensitive to cephalosporins s p ceftriaxone x1 in ed macrobid stopped covered by keflex and doxy for ulcers repeat ua negative gross hematuria painless episodes ua negative for blood rbc recommended outpatient follow up with urology chronic issues htn lisinopril mg held bps mostly 120s 140s please restart as appropriate transitional issues f u on healing of r groin ulcers abscesses r buttock ulcer l heel ulcer continue daily bid wound dressing changes antibiotics through unless continuing concern for infection increase fycompa to mg qhs on follow up in week with rn follow up with dr surgeon within weeks of discharge follow up with urology for painless hematuria within month monitor blood pressure and restart home lisinopril mg as appropriate medications on admission the preadmission medication list is accurate and complete sevelamer carbonate mg po tid w meals prednisone mg po daily famotidine mg po daily albuterol inhaler puff ih q4h prn shortness of breath levetiracetam mg po bid lamotrigine mg po tid phenobarbital mg po bid lorazepam mg po daily prn anxiety ferrous sulfate mg po bid hydroxyzine mg po q6h prn anxiety lisinopril mg po daily gabapentin mg po tid budesonide formoterol mcg actuation inhalation bid discharge medications cephalexin mg po qid rx cephalexin mg capsule s by mouth four times a day disp capsule refills collagenase ointment appl tp daily doxycycline hyclate mg po bid rx doxycycline hyclate mg capsule s by mouth twice a day disp tablet refills fycompa perampanel mg oral qhs rx perampanel fycompa mg tablet s by mouth at bedtime disp tablet refills rx perampanel fycompa mg tablet s by mouth at bedtime disp tablet refills polyethylene glycol g po daily pramipexole mg po qhs sarna lotion appl tp daily prn itching gabapentin mg po tid prn pain albuterol inhaler puff ih q4h prn shortness of breath budesonide formoterol mcg actuation inhalation bid famotidine mg po daily ferrous sulfate mg po bid hydroxyzine mg po q6h prn anxiety lamotrigine mg po tid levetiracetam mg po bid phenobarbital mg po bid prednisone mg po daily sevelamer carbonate mg po tid w meals held lisinopril mg po daily this medication was held do not restart lisinopril until necessary for high blood pressure discharge disposition extended care facility discharge diagnosis seizure disorder secondary diagnoses urinary tract infection right groin abscess left heel ulcer copd left tibia fibular fractures discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear ms you were admitted to due to new episodes of tongue heaviness and difficulty speaking you were monitored on eeg which showed that these episodes are seizures in addition you had dozens of subclinical seizures each day which you do not notice we think you are having more seizures due to infections you were found to have a urinary tract infection which has been treated with antibiotics you also had ulcers on your left heel and your right buttock an abscess was found in your right groin which needed to be lanced and drained by the surgery team you were treated for days with antibiotics called keflex and doxycycline take your medications as prescribed you were started on an additional anti seizure medication fycompa perampanel mg at bedtime on increase to mg at bedtime you are being treated on antibiotics through keep taking cephalexin mg four times a day stop after keep taking doxycycline mg twice a day stop after your lisinopril mg daily was held temporarily while in the hospital please see your pcp about whether you should restart it for your blood pressure continue all your other medications as prescribed follow up with your pcp weeks of discharge you had a couple episodes of painless blood in your urine this may be completely benign but there is a possibility that sometimes it is an early sign of bladder or kidney cancer you should see your pcp or urologist within the next month to follow up on blood in your urine follow up with your orthopedic surgeon dr in weeks he suggests calling his office to make an appointment follow up with your neurologist within months thank you for the opportunity to care for you sincerely the neurology team followup instructions

name unit no admission date discharge date date of birth sex m service surgery allergies floctafenine attending chief complaint acute pancreatitis major surgical or invasive procedure laparoscopic cholecystectomy laparoscopic cholecystectomy dr history of present illness pt is y o male with hx of hypertriglyceridemia htn osa dmii neuropathy essential tremor and prior diagnosis of acute pancreatitis weeks ago at in after experience abdominal pain nausea vomiting and several episodes of loose stools ct at that time was notable for mild acute pancreatitis duodenitis a high density fluid collection posterior to the pancreatic tail and a small nonocclusive filling defect in smv suspicious for thrombus patient underwent ivf resuscitation and with an hospital course and was subsequently discharged home since discharge pt states he as been unable to tolerate po intake eating solid food once in the past days while traveling for a funeral the past couple of day his emesis abdominal pain and diarrhea have intensified culminating in evaluation at where ct findings were again notable for edema and inflammation around the pancreas fluid collection in both the tail 7x3 1cm and head 9x2 2cm of the pancreas as well fluid extending down the right abdomen on presentation pt is not in acute distress persistently hypotensive systolic despite receiving 3l at the osh endorsing continued abdominal pain dry mouth diarrhea a frustrating lack of po intake pt denies nausea vomiting today chest pain loc prior mi melena or headache past medical history past medical history dmii htn hld acute pancreatitis neuropathy osa essential tremor past surgical history spinal stimulator placement c spine fusion social history family history non contributory physical exam admission physical exam vitals po r lying ra gen a o nad heent no scleral icterus mucus membranes moist cv hypotensive regular rhythm pulm clear to auscultation b l no wheezin abd soft obese nondistended mild epigastric tenderness no rebound or guarding normoactive bowel sounds ext no edema warm and well perfused discharge physical exam vs po ra gen nad axox3 card rrr no m r g pulm ctab no respiratory distress abd soft non tender non distended normal bs njt in place wounds c d i ext no edema warm well perfused pertinent results imaging duplex dopp abd pel port patent hepatic vasculature limited evaluation of the splenic vein and superior mesenteric vein the visualized portions of the splenic and superior mesenteric veins appear patent diffusely echogenic liver suggestive of a degenerative cyst or intrinsic liver disease heterogeneous collections adjacent to the spleen as on the prior ct likely sequela of known pancreatitis cholelithiasis without evidence of acute cholecystitis cta abdomen pelvis multiple peripancreatic collections are unchanged from recent prior nonocclusive thrombus in the splenic vein a second order jejunal branch of the smv is narrowed however remains patent upper endoscopic ultrasound normal mucosa in the whole esophagus normal mucosa in the whole stomach multiple shallow nonbleeding clean based ulcers in the examined duodenum expected in setting of acute pancreatitis eus markedly edematous and distorted pancreatic parenchyma in setting of acute pancreatitis several acute pancreatic and peripancreatic fluid collections identified the cbd could not be assessed due to distorted in anatomy in setting of acute pancreatitis nasojejunal tube placed at the end of the procedure portable abdominal x ray there is a nasojejunal tube which terminates in the expected region of the proximal jejunum in the left hemiabdomen there are no abnormally dilated loops of large or small bowel there is no free intraperitoneal air although evaluation is limited by supine technique a spinal cord stimulator device projects over the right side of the abdomen no acute osseous abnormalities are identified ct interventional radiology procedure sample cc of milky fluid was aspirated from the right paracolic gutter collection sample cc of straw colored blood tinged fluid was aspirated from the peripancreatic collection impression technically successful ct guided aspiration of the collections as described above labs 14am lactate 59am glucose urea n creat sodium potassium chloride total co2 anion gap 59am alt sgpt ast sgot ld ldh alk phos tot bili 59am lipase 59am albumin calcium phosphate magnesium 59am triglycer 59am wbc rbc hgb hct mcv mch mchc rdw rdwsd 59am neuts lymphs monos eos basos absneut abslymp absmono abseos absbaso 59am hypochrom anisocyt macrocyt 59am plt smr high plt count 59am ptt 50pm urine color straw appear clear sp 50pm urine blood tr nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg 50pm urine rbc wbc bacteria none yeast none epi 50pm urine hyaline 49pm lactate 39pm glucose urea n creat sodium potassium chloride total co2 anion gap 39pm alt sgpt ast sgot alk phos tot bili 39pm lipase 39pm albumin 39pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 39pm neuts monos eos basos myelos absneut abslymp absmono abseos absbaso 39pm rbcm within nor 39pm rbcm within nor brief hospital course mr is a y o male with hx of hypertriglyceridemia htn osa dmii neuropathy essential tremor and recent diagnosis of acute pancreatitis at in after experiencing abdominal pain nausea vomiting and several episodes of loose stools he was discharged from and then later presented at in with abdominal pain and emesis ct findings at were again notable for edema and inflammation around the pancreas fluid collection in both the tail 7x3 1cm and head 9x2 2cm of the pancreas as well fluid extending down the right abdomen the patient was transferred to in hypovolemic shock and was admitted to the acute care surgery service on blood culture from grew staphylococcus coagulase negative and he was started on vancomycin repeat blood cultures were sent which were negative and vancomycin was discontinued the patient was transferred to the icu and was made npo with ivf for hydration gastroenterology was consulted for endoscopy abdominal ultrasound revealed gallstones and his pancreatitis was thought to be due to gallstone pancreatitis on cta was done to evaluate for smv thrombus and a nonocclusive thrombus was seen in the splenic vein the patient was started on a heparin drip which was later transitioned to warfarin with lovenox bridging on the patient went for upper endoscopy with gastroenterology which revealed multiple shallow nonbleeding clean based ulcers in the examined duodenum a markedly edematous and distorted pancreatic parenchyma in the setting of acute pancreatitis several acute pancreatic and peripancreatic fluid collections the cbd could not be assessed due to distorted anatomy in the setting of acute pancreatitis a nasojejunal tube was placed so that the patient could receive tube feedings tube feeds were initiated on which the patient tolerated tube feeds were later changed from continuous to cycled on the patient was taken to the operating room where he underwent laparoscopic cholecystectomy this procedure went well reader please refer to operative note for details after remaining hemodynamically stable in the pacu the patient was transferred to the surgical floor pain was managed with a hydromorphone pca initially on pod the pca was d c d and oxycodone and acetaminophen were prescribed the patient continued on tube feeds which he tolerated given that the patient lives in follow up care appointments were arranged in his home state please see discharge worksheet for further details inr check all other inr check with primary care doctor in dr at the time of discharge the patient was doing well afebrile with stable vital signs the patient was tolerating tube feeds ambulating voiding without assistance and pain was well controlled the patient was discharged home with services for tube feeds 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 atenolol chlorthalidone mg oral daily duloxetine mg po daily fenofibrate mg po daily gabapentin mg po tid lisinopril mg po daily metformin xr glucophage xr mg po bid nortriptyline mg po qhs primidone mg po tid aspirin mg po daily discharge medications docusate sodium mg po bid rx docusate sodium colace mg capsule s by mouth twice a day disp capsule refills enoxaparin sodium mg sc q12h rx enoxaparin mg ml mg sc every twelve hours disp syringe refills oxycodone immediate release mg po q4h prn pain moderate rx oxycodone oxaydo mg tablet s by mouth every four hours disp tablet refills warfarin mg po once duration dose rx warfarin coumadin mg tablet s by mouth once a day disp tablet refills atenolol chlorthalidone mg oral daily duloxetine mg po daily fenofibrate mg po daily gabapentin mg po tid lisinopril mg po daily metformin xr glucophage xr mg po bid nortriptyline mg po qhs primidone mg po tid discharge disposition home with service facility discharge diagnosis non occlusive thrombus in the splenic vein months lovenox and warfarin fluid collections negative gram stain on aspiration cholelithaisis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear were admitted to and underwent laparoscopic cholecystectomy during your hospitalization also had the interventional radiology team aspirate a sample of the fluid collections seen on the ct scan these cultures were negative are recovering well and are now ready for discharge please follow the instructions below to continue your recovery anticoagulation have a partial splenic thrombus seen on the ct scan are on a lovenox bridge until your inr is goal also need to take warfarin for months follow up with primary care doctor in your pcpc will monitor your anticoagulation in the office for inr checks avoid changes in diet with foods rich in vit k broccoli spinach cauliflower sprouts your health records were sent to dr surgery clinic office at the medical is dr assistant the office will review your record then contact in the next days to be assigned to dr another surgeon for your post operative appointment s can call if have any questions this arrangement was coordinated on your behalf due to preference to follow up in visiting nurses will have services for week in for nutrition feeding education and supplies this company will connect with services in if still needed follow ups primary care doctor inr blood test goal inr blood sugar and medication reconciliation please go to your primary care doctor post operative check from laparoscopic cholecystectomy and splenic vein thrombus at 30pm post operative and a one time inr check your primary care doctor will be following all additional inr checks please go the blood lab before your clinic appointment to have labs drawn clinic number activity o do not drive until have stopped taking pain medicine and feel could respond in an emergency o may climb stairs o may go outside but avoid traveling long distances until see your surgeon at your next visit o don t lift more than lbs for weeks this is about the weight of a briefcase or a bag of groceries this applies to lifting children but they may sit on your lap o may start some light exercise when feel comfortable o will need to stay out of bathtubs or swimming pools for a time while your incision is healing ask your doctor when can resume tub baths or swimming how may feel o may feel weak or washed out for a couple of weeks might want to nap often simple tasks may exhaust o may have a sore throat because of a tube that was in your throat during surgery o might have trouble concentrating or difficulty sleeping might feel somewhat depressed o could have a poor appetite for a while food may seem unappealing o all of these feelings and reactions are normal and should go away in a short time if they do not tell your surgeon your incision o tomorrow may shower and remove the gauzes over your incisions o your incisions may be slightly red around the stitches this is normal o may gently wash away dried material around your incision o avoid direct sun exposure to the incision area o do not use any ointments on the incision unless were told otherwise o may see a small amount of clear or light red fluid staining your dressing or clothes if the staining is severe please call your surgeon o may shower as noted above ask your doctor when may resume tub baths or swimming your bowels o constipation is a common side effect of narcotic pain medications if needed may take a stool softener such as colace one capsule or gentle laxative such as milk of magnesia tbs twice a day can get both of these medicines without a prescription o if go hours without a bowel movement or have pain moving the bowels call your surgeon pain management o it is normal to feel some discomfort pain following abdominal surgery this pain is often described as soreness o your pain should get better day by day if find the pain is getting worse instead of better please contact your surgeon o will receive a prescription for pain medicine to take by mouth it is important to take this medicine as directed o do not take it more frequently than prescribed do not take more medicine at one time than prescribed o your pain medicine will work better if take it before your pain gets too severe o talk with your surgeon about how long will need to take prescription pain medicine please don t take any other pain medicine including non prescription pain medicine unless your surgeon has said its okay o if are experiencing no pain it is okay to skip a dose of pain medicine o remember to use your cough pillow for splinting when cough or when are doing your deep breathing exercises if experience any of the following please contact your surgeon sharp pain or any severe pain that lasts several hours pain that is getting worse over time pain accompanied by fever of more than a drastic change in nature or quality of your pain medications take all the medicines were on before the operation just as did before unless have been told differently if have any questions about what medicine to take or not to take please call your surgeon followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies no known allergies adverse drug reactions attending chief complaint substernal chest pain st elevation myocardial infarction complicated by complete heart block major surgical or invasive procedure cardiac catheterization via right radial artery with pci percutaneous coronary intervention percutaneous coronary intervention pci was performed on an ad hoc basis based on the coronary angiographic findings from the diagnostic portion of this procedure a jr4 guide provided adequate support crossed with a choice wire into the distal pda predilated with a mm balloon a mm x mm des was deployed the stent was post dilated again with a nc balloon final angiography revealed normal flow no dissection and residual stenosis history of present illness mr is a y o m w htn gerd treated hcv and pre diabetes presenting for chest pain found to have anterolateral stemi complicated by complete heart block patient was in his usual state of health until afternoon he states early in the afternoon he started to notice some abdominal pain after eating around he took a few tums and then took a nap after the nap he noted no improvement in his pain and had new substernal chest pressure the pain did not radiate but gradually worsened and he became more diaphoretic this prompted him to call ems who transported him here while in transport he was found to have ekg findings concerning for a stemi and 3rd degree heart block however he remained normotensive with hr he was given a full dose asa and fentanyl in the ed initial vitals were hr bp resp o2 sat on ra exam notable for patient appeared ill was diaphoretic noted to be bradycardic labs notable for trop and ck mb studies notable for ekg with complete heart block st elevation in ii iii avf v3 v6 patient was given atorvastatin ticagrelor loading dose and started on heparin ggt patient was immediately taken to the cath lab where the culprit lesion was felt to be a stenosis of the proximal rca for which a des was placed he was also noted to have stenosis of the mid segment of the lad which was not intervened upon the procedural course was complicated by worsening bradycardia and hypotension thought likely to be a vagal response given increased sensitivity in the setting of his rca lesion following intervention his ekg returned to normal sinus rhythm with symptomatic and hemodynamic improvement on arrival to the ccu patient reiterates story as above his biggest complaint is nausea but notes his chest pain has improved markedly past medical history cardiac history htn other pmh gerd hcv treated with ribavirin and interferon in neg vl in no evidence of cirrhosis social history family history father who passed away from an mi in his mother with mi in her physical exam admission physical examination vs reviewed in metavision general fatigued appearing male in no acute distress heent normocephalic atraumatic no jvd appreciated cardiac normal rate regular rhythm no murmurs rubs or gallops lungs no increased work of breathing clear to auscultation bilaterally abdomen soft non tender non distended extremities warm well perfused no clubbing cyanosis or peripheral edema tr band in place over right wrist small hematoma directly proximal larger hematoma near antecubital fossa neuro cnii xii grossly intact discharge physical examination ra general no acute distress well appearing cardiovascular regular rate rhythm no murmur respiratory lungs clear bilaterally breathing non labored abdomen soft non tender bs extremities ble warm no edema skin warm dry and intact neuro alert oriented appropriate no focal deficits access site right radial access site with fading bruising area is soft to palpation with intact radial pulse and distal sensation pertinent results cardiac catheterization 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 there is an stenosis in the mid segment 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 stenosis in the mid segment the obtuse marginal arising from the proximal segment is a medium caliber vessel the obtuse marginal arising from the mid segment is a medium caliber vessel rca the right coronary artery arising from the right cusp is a large caliber vessel there is a stenosis in the proximal segment there is a stenosis in the mid segment the right posterior descending artery arising from the distal segment is a medium caliber vessel the right posterolateral artery arising from the distal segment is a medium caliber vessel percutaneous coronary intervention percutaneous coronary intervention pci was performed on an ad hoc basis based on the coronary angiographic findings from the diagnostic portion of this procedure a jr4 guide provided adequate support crossed with a choice wire into the distal pda predilated with a mm balloon a mm x mm des was deployed the stent was post dilated again with a nc balloon final angiography revealed normal flow no dissection and residual stenosis transthoracic echocardiogram conclusion the left atrial volume index is normal there is normal left ventricular wall thickness with a normal cavity size there is moderate regional left ventricular systolic dysfunction with basal inferoseptal and inferior akinesis as well as basal to mid inferolateral hypokinesis see schematic overall left ventricular systolic function is mildly depressed quantitative biplane left ventricular ejection fraction is normal left ventricular cardiac index is normal l min m2 there is no resting left ventricular outflow tract gradient there is grade i diastolic dysfunction normal right ventricular cavity size with mild global free wall hypokinesis the aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender the aortic valve leaflets appear structurally normal there is no aortic valve stenosis there is no aortic regurgitation the mitral valve leaflets appear structurally normal with no mitral valve prolapse there is trivial mitral regurgitation the pulmonic valve leaflets are normal the tricuspid valve leaflets appear structurally normal there is mild to moderate tricuspid regurgitation the estimated pulmonary artery systolic pressure is normal there is no pericardial effusion impression mild global and moderate focal lv systolic dysfunction c w prior myocardial infarction in rca territory with large plv branch to supply inferolateral wall admission labs 49pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 49pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 49pm blood glucose urean creat na k cl hco3 angap 49pm blood alt ast ld ck cpk alkphos totbili 49pm blood albumin calcium phos mg 49pm blood ctropnt 49pm blood ck mb probnp 20am blood hba1c eag 27pm blood triglyc hdl chol hd ldlcalc discharge labs 09am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 09am blood urean creat na k cl hco3 angap 09am blood alt ast liver function tests 49pm blood alt ast ld ck cpk alkphos totbili 20am blood alt ast alkphos totbili 58am blood alt ast alkphos totbili 09am blood alt ast brief hospital course s p stemi c b complete heart block s p pci to proximal rca occlusion with additional findings of mid lad disease coronaries lad lcx rca stenosis s p pump ef rhythm sinus inferior stemi initial ekg with inferolateral ste iii ii with st depressions in avl and complete heart block ekg on discharge with t wave inversions and q waves ii iii and avf and twi v3 v6 sinus rhythm rate normal intervals now s p revascularization as above aspirin 81mg daily ticagrelor loaded continue at 90mg bid atorvastatin 80mg daily metoprolol succinate 25mg daily losartan home dose 50mg daily resumed on needs pci for mid lad disease recommended to be done this admission however patient strongly prefers to go home and return for planned pci at a later date outpt cardiac rehab once lad revascularized complete heart block resolved new onset in setting of inferolateral stemi rca occlusion resolved following revascularization transaminitis improved during recovery hypertension home losartan resumed on metoprolol added as noted medications on admission the preadmission medication list is accurate and complete losartan potassium mg po daily clindamycin solution appl tp bid discharge medications aspirin mg po daily atorvastatin mg po qpm metoprolol succinate xl mg po daily nitroglycerin sl mg sl q5min prn chest pain ticagrelor mg po bid clindamycin solution appl tp bid losartan potassium mg po daily discharge disposition home discharge diagnosis coronary artery disease stemi hypertension discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent vs ra general alert no acute distress cardiovascular regular rate rhythm no murmur respiratory lungs clear bilaterally breathing non labored abdomen soft non tender bs extremities ble warm no edema skin warm dry and intact neuro alert oriented appropriate access site right radial access site with surrounding bruising area is soft to palpation with intact radial pulse and distal sensation discharge instructions you were admitted to the hospital because you had a heart attack you had an urgent cardiac catheterization procedure in which a drug coated stent was placed to open a blockage in your right coronary artery rca your heart also went into a dangerous rhythm complete heart block which resolved following this procedure it was also found that you have a blockage in your left anterior descending lad heart artery and this needs to be stented to prevent you from having another heart attack it was strongly recommended that this be done now however you have decided to go home and return at a later time for this procedure please keep your appointment with bellow a number of medications have been given to you and should be continued these include aspirin 81mg daily you should take this for life ticagrelor 90mg twice a day you should take this for a minimum of one year and only stop when told by a cardiologist specifically ticagrelor and aspirin are extremely important medications taken to prevent blood clots from forming in the stents in your heart stopping either of these medications too early puts you at high risk for a life threatening heart attack atorvastatin 80mg daily best absorbed when taken in the evening this medication not only reduces cholesterol but has been shown to help decrease risk of heart attack in the future for people who have coronary artery heart disease metoprolol this medication belongs to a class of medications known as beta blockers beta blockers slow the heart down and can lower blood pressure they help reduce the amount of work the heart has to do and can reduce risk of future heart attack losartan 50mg daily you were taking this at home and you should continue taking it as prescribed nitroglycerin nitroglycerin is a medication that is used as needed for chest pain if you develop chest pain place tablet under the tongue and allow it to dissolve if after minutes you are still having chest pain you can repeat this every minutes for up to doses it was a pleasure to have participated in your care because we know that you have a coronary lesion blockage that has not yet been stented it is extremely important that you return to the hospital right away call for evaluation if you develop recurrent symptoms if you have other questions related to recovery from your procedure you can call the heart line at to page us and receive a call back from a cardiologist or cardiac nurse practitioner followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies tree nut attending chief complaint back pain major surgical or invasive procedure pamidronate velcade history of present illness mr is a very pleasant with history of igg multiple myeloma diagnosed last week in the workup of non traumatic t spine fracture who presents with acute on chronic back pain and new foot numbness mr recent medical history is notable for presenting to his pcp with one month of mid back pain at that visit he reported that while he has a history of low back pain he had started to have pain in his mid back that was not getting better on exam he was noted to have point tenderness along his thoracic spine with pain raditating across his rib cage he reports the pain was better with rest and while supine on a hard surface was worse with activity and worse with wearing a backpack he had a thoracic spine xray which showed loss of height of t7 vertabrae and was referred to orthopaedics an mri t spine was obtained which showed multiple compression fractures the most severe at t7 without definite paraspinal or bone marrow edema to suggest acute fractures the visualized bone marrow signal intensity is diffusely abnormal with increased in stir signal which could be related to hematopoietic marrow hyperplasia or an infiltrative process slight retropulsion of fragments at the superior aspect of t7 indents the spinal cord minimally dorsally the subarachnoid space is widely patent rostral to this level there is a hydromyelia likely secondary to the slight mass effect on the spinal cord he was then referred to dr evaluation he had a iliac bone marrow biopsy on the results of which are still pending blood tests showed an elevated igg thus the presumed diagnosis of multiple myeloma was made and it was recommended that he start rvd zometa on he reports that he was doing well up until yesterday when he was bending down to pick something up and had acute worsening of his pain he reported that he also began to feel numbness over toes bilaterally he had continued pain overnight and in the morning was unable to get oob tonight and was unable due to pain he called and was taken to ed in the ed initial vs were ra exam notable for normal rectal tone normal perianal sensation labs were notable for normal wbc na of imaging included ct l spine with diffuse bony disease mri of c t l spine was obtained consults called none though was asked by primary team to get spine consult in ed treatments received iv morphine sulfate mg iv ondansetron mg iv morphine sulfate mg iv diazepam mg vitals prior to transfer were today ra today nasal cannula on arrival to the floor patient stable lying flat in bed wife at bedside pain increasing as last morphine dose about hrs prior no urinary incontinence or retention no saddle anesthesia no ivda denies any trauma no fevers or chills past medical history past oncologic history multiple myeloma diagnosed initiated rvd past medical history de quervain s tenosynovitis right colon polyp vitamin d deficiency anemia social history family history father cad pvd early stroke maternal grandmother mother unknown type physical exam admission physical exam vs 95ra gen well appearing man in mild distress lying flat in bed heent op clear no scleral icterus eomi cv rr normal s1 s2 no m r g pulm ctab abd soft nd nt nab gu no foley gi normal anal sphincter tone ext no evidence of clubbing cyanosis or edema pulses radial and dp warm well perfused skin without rashes wounds or lesions suspicious for malignancy neuro aox3 cn ii xii in tact extremities ue b l normal strength and sensation b l strength with flexion and extension of hip knee ankle great toe normal sensation to light touch and temperature no level identified sphincter tone normal negative babinski no clonus reflexes b l patellar achillies psych not currently depressed good insight access rue discharge physical exam vs ra gen aox3 non ill appearing male sitting upright without brace in no discomfort heent eomi op clear w mmm cv normal s1 s2 no m r g pulm lungs cta b l without w r r abd active bs nd nt gu no foley ext no edema pulses radial and dp warm well perfused skin without rashes wounds or lesions suspicious for malignancy or infection neuro aox3 cn ii xii intact extremities no evidence of mm atrophy rom deferred pain on prior exams with motion reflexes bilateral patellar achilles psych possible adjustment related depression access rue pertinent results admission laboratory values 57am wbc rbc hgb hct mcv mch mchc rdw rdwsd 57am neuts monos eos basos im absneut abslymp absmono abseos absbaso 57am plt count 57am osmolal 57am glucose urea n creat sodium potassium chloride total co2 anion gap 57am calcium phosphate magnesium 57am urine blood neg nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg 57am urine color straw appear clear sp 57am urine u pep no protein osmolal 57am urine hours random urea n creat sodium potassium chloride tot prot prot crea pertinent imaging skeletal survey skull rounded lucency over the anterior parietal bone is non specific and could represent a vascular channel otherwise no suspicious lytic lesions identified thoracic spine right convex scoliosis and severe osteopenia with compression of multiple upper thoracic vertebral bodies more completely visualized on spine mri background degenerative changes present lumbar spine no osteopenia degenerative change common very mild left convex curvature mild endplate scalloping at l2 and l5 these abnormalities are better depicted on the l spine ct and mri from pelvis and hips the sacrum is considerably obscured by overlying bowel gas allowing for this there is an equivocal rounded lucency at the lateral border of the right a ischial tuberosity measuring approximately mm otherwise no suspicious focal lytic lesion is identified mild degenerative spurring of both hips is noted right and left femur no obvious focal lytic lesions detected right and left humerus equivocal tiny mm scattered lucencies in the proximal and mid humerus on both sides mild degenerative changes noted in both shoulders impression diffuse osteopenia no large lytic lesions identified equivocal lucencies in the skull and bilateral humeri note is made that there was diffuse marrow abnormality on the l spine mri from raising the question of diffuse marrow infiltration compression fractures in the thoracic spine and vertebral body endplate scalloping in the lumbar spine more completely depicted on the recent ct and mri studies degenerative changes of the thoracic and lumbar spine noted mild degenerative changes of the shoulders and hips are also present discharge laboratory values 32am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 32am blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 32am blood plt 32am blood alt ast alkphos totbili 32am blood albumin calcium phos mg 20am blood hbsag negative hbsab negative hbcab negative hav ab negative igm hbc negative igm hav negative brief hospital course with history of igg multiple myeloma diagnosed week prior to admission during the workup of non traumatic t spine fracture who presented with acute on chronic back pain spinal mri on admission showed no evidence of spinal cord compression but with numerous osteolytic lesions of the spine long bone survey with minimal osteolytic involvement he was seen by orthopaedic who recommended a tlso brace when oob for comfort and safety he was started on bortezomib velcade and dexamethasone on and received second dose on he was given pamidronate on during admission he was noted to have low neutrophil count and became neutropenic anc and febrile without localizing source he was started on cefepime and had resolution of fevers and neutropenia and then was transitioned to levofloxacin for seven day antibiotic course for presumed pneumonia he was followed by physical therapy and cleared to return home with physical therapy and occupational therapy services at home he will be seen in clinic on to receive third dose of bortezomib additionally at time of d c started revlimid and asa 81mg back pain patient with known diffuse spinal involvement of mm and known t7 compression fracture acute worsening concerning for further compression however mri c t l spine was reassuring for lack of cord impingement persistent uncontrolled pain localized to lumbar mid spine mr had been declining prn pain medication discussion with patient to help him better understand current physical state and that it is okay to need pain medications right now he agreed that would have a better quality of life if we control his pain presently patient was seen by ortho md who recommended use of tlso brace with activity this alleviated a degree of his pain patient course was complicated by constipation most likely secondary to both inability to get to bathroom prn as well as pain when defecating limiting effort in turn constipation contributed to lower back pain with prn use of pain medication and support brace his pain was controlled to degree patient willing to tolerate sedentary side effects of opiates febrile neutropenia first spiked fevers as high as subsequently developed neutropenia admission nadir anc unclear etiology initiation of velcade and dexamethasone scheduled for were held at this time no obvious precipitating factor started on cefepime for febrile neutropenia results of recent marrow tap not finalized however per conversation with primary oncology team some samples showing range of plasma cell predominance patient w mm puts at risk for infection given functional hypogammaglobulinemia bone marrow crowding is possible however is now s p two doses of bortezomib which usually has a more rapid marrow response possible other etiologies include viral etiology such as cmv and ebv as patient has concordant transaminitis no other known recent sick contacts prior to hospitalization did not at present have any localizing symptoms tls not common in mm cxr at time of fever w o evidence of consolidation however cannot rule out pneumonia and not aspiration risk or concern for pneumonitis no abdominal pain or diarrhea suggestive of noro or c diff had one large formed bm yesterday to great relief no recent proceduralization fevers broke all infectious studies and imaging to date of discharge negative given transaminitis specific viral etiologies considered ebv cmv also negative ruqus revealed no concerning biliary or hepatic pathology anc at d c plan was to continue empiric course of days levofloxacin until completion constipation had sparse use of pain medications at home pta no use of opioids had been having intermittent bm since admission and use of opioids has not had significant bm abdominal exam is soft but full pain has limited ability to physically make it to toilet initially since initation of brace has felt he cannot valsalva well however pain has limited effort as well discussed need to continue to use opioids despite their contribution to constipation as they will enable ability to push trial with polyethylene glycol did not produce bms responded immediately with sips of mag citrate ginger ale transaminitis noted elevation of lfts alt ast now alt ast alk phos and tbili wnl and unchanged during this time period inr stably likely medication side effect from acetaminophen responsible for uptrending transaminiases responded to d c of acetominophen no other current medications w known hepatotoxicity bortezomib not typically associated with liver toxicity no other recent illness or localizing symptoms possible viral etiologies include hepatidities cmv ebv hiv no hx hiv no current clinical suspicion for hiv all other studies negative to date at time of d c recomment vaccination as above multiple myeloma igg multiple myeloma diagnosed last week in the workup of non traumatic t spine fracture symptoms concerning for possible progression of disease involving l spine with pathologic fracture sustained when bent over to clean cat litter box originally due for initation of rvd treatment this coming as outpatient but initiated on skeletal survey showing diffuse osteopenia no large lytic lesions identified equivocal lucencies in the skull and bilateral humeri note is made that there was diffuse marrow abnormality on the l spine mri from raising the question of diffuse marrow infiltration compression fractures in the thoracic spine and vertebral body endplate scalloping in the lumbar spine more completely depicted on the recent ct and mri studies degenerative changes of the thoracic and lumbar spine noted mild degenerative changes of the shoulders and hips are also present patient was intended to begin velcade and dexamethasone held for febrile neutropenia fever resolved and chemo started first dose revlimid and asa 81mg hyponatremia currently asx and aox3 probable contribution of pseudohyponatremia secondary to hyperproteinemia igg as urine osmolarity is inappropriately normal and we would expect increased urine osmolarity transition issues code status full confirmed hcp wife spouse f up pcp primary oncology and ortho spine as outpatient patient at higher risk for dvt pe would consider outpatient lovenox pain regimen bowel regimen depression coping follow up hepatitidies viral negative recommend revaccination with hep a b f up anc outpt avoid tylenol prn pain fevers hx precipitating transaminitis patient discharged on levofloxacin to complete day antibiotic course for neutropenia course to end medications on admission the preadmission medication list is accurate and complete ondansetron mg po q8h prn nausea prochlorperazine mg po q6h prn nausea omeprazole mg po daily vitamin d unit po 1x week dexamethasone mg po once dexamethasone mg po once acyclovir mg po q12h lorazepam mg po q6h prn anixety insomnia tramadol ultram mg po q8h prn pain discharge medications acyclovir mg po q12h lorazepam mg po q6h prn anixety insomnia omeprazole mg po daily prochlorperazine mg po q6h prn nausea tramadol ultram mg po q8h prn pain rx tramadol mg tablet s by mouth every eight hours disp tablet refills bortezomib mg sc days and and mg m2 weight used actual weight kg bsa m2 ondansetron mg po q8h prn nausea vitamin d unit po 1x week equipment standard cane length of need months prognosis good icd10 r26 equipment rolling walker length of need months prognosis good icd10 r26 docusate sodium mg po bid polyethylene glycol g po daily prn constipation senna mg po bid levofloxacin mg po daily duration doses rx levofloxacin levaquin mg tablet s by mouth daily disp tablet refills oxycodone immediate release mg po q4h prn breakthrough pain rx oxycodone mg capsule s by mouth every six hours disp capsule refills aspirin mg po daily lenalidomide mg po daily for each cycle weeks take one tablet daily for d1 and none day weeks on off dexamethasone mg po asdir discharge disposition home with service facility discharge diagnosis primary back pain pathologic fracture of t5 and t7 vertebral bodies febrile neutropenia secondary multiple myeloma discharge condition mental status clear and coherent level of consciousness alert and interactive activity status please wear tlso brace when out of bed discharge instructions dear mr it was a pleasure meeting you and taking care of you you were admitted with severe back pain caused by your multiple myeloma we obtained imaging that showed no compression of your spine cord which was reassuring you were started on treatment for your multiple myeloma and you we were able to find a balance of pain medication that you felt was appropriate enough to decrease pain without limiting your daily function further you were found to possibly have an infection and will need to finish your course of antibiotics best your team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies tree nut bactrim attending chief complaint admit for hd cytoxan prior to stem cell mobilization major surgical or invasive procedure none history of present illness year old male with mm s p cycles rvd now admitted for cytoxan stem cell mobilization bone marrow biopsy showed of aspirate plasma cells significant reduction compared to prior was of aspirate states previously had leg swelling on dex but none currently otherwise no headaches cough sore throat fevers rash abd pain diarrhea chest pain sob constipation brbpr melena all other point ros neg review of systems general no fever chills night sweats recent weight changes heent no sores in the mouth painful swallowing intolerance to liquids or solids sinus tenderness rhinorrhea or congestion cards no chest pain chest pressure exertional symptoms or palpitations pulm no cough shortness of breath hemoptysis or wheezing gi no nausea vomiting diarrhea constipation or abdominal pain no recent change in bowel habits hematochezia or melena gu no dysuria or change in bladder habits msk no arthritis arthralgias myalgias or bone pain derm denies rashes itching or skin breakdown neuro no headache visual changes numbness tingling paresthesias or focal neurologic symptoms psych no feelings of depression or anxiety all other review of systems negative past medical history onc history regarding his myeloma his presentation is notable for a history of worsening back pain for month which when worked up by mri demonstrated multiple compression fractures and a bm signal intensity c f myeloma w u revealed leukopenia wbc anemia hgb cr ca alb igg of m spike with 2g dl iga and igm with kappa lambda ratio of b2 microglobulin of bmbx on demonstrated infiltrate with plasma cells c w with a dx of stage iii igg 7g dl and advanced lytic lesions iss stage iii beta 5mg dl was started on rvd by dr on has tolerated it fairly well and has completed cycles past medical history lower back pain past surgical history tonsillectomy eye surgery for lazy eye right hand surgery social history family history siblings brother with soft tissue sarcoma on knee mother no known history of cancer or blood disorders father no known history of cancer or blood disorders still alive year old aunts no known history of cancer or blood disorders uncles no known history of cancer or blood disorders maternal grandmother no known history of cancer or blood disorders died of unknown type maternal grandfather no known history of cancer or blood disorders lived to paternal grandmother no known history of cancer or blood disorders paternal grandfather no known history of cancer or blood disorders children no known history of cancer or blood disorders physical exam vital signs ra general nad heent mmm no op lesions cv rr nl s1s2 no s3s4 mrg pulm ctab gi bs soft ntnd no masses or hepatosplenomegaly limbs no edema clubbing tremors skin no rashes or skin breakdown neuro oriented x3 non focal pertinent results 33am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 40pm blood na 00pm blood na 30pm blood na 01am blood na 38am blood glucose urean creat na k 00pm blood glucose urean creat na k 24am blood glucose urean creat na k cl hco3 angap w mm s p cycles rvd admitted for cytoxan stem cell mobilization c b mod severe hyponatremia hyponatremia na dropped from to within hrs with associated ha but no ms changes was seen by nephrology considering the elevated una and osms along with clinical history of cytoxan induced nausea and ongoing aggressive ivf administration it was thought that this was adh induced hyponatremia from cytoxan related nausea was placed on 1l po fluid restriction and salt tabs and na improved to back to within hrs his symptoms improved and was monitored overnight without po restrictions and nacl tabs and his na remained normal on will need to have his sodium monitored carefully if will receive cytoxan again mm completed rvd bm bx with plasma cells in aspirate and in marrow significant reduction from was admitted for cytoxan mobilization and completed it with the complication of hyponatremia and nausea started cipro and zarxio has scripts and zarxio at home sc collection in days c w zometa as outpatient plan for upcoming auto transplant per monitor for nausea with chemo anti emetics prn ppx cont acyclovir pt taking bid reports lower back pain h o compression fractures at t5 t7 chronic cont prn oxy tramadol d o heme hospitalist medications on admission the preadmission medication list is accurate and complete acyclovir mg po q12h lorazepam mg po q8h prn nausea insomnia anxiety ondansetron mg po q8h prn nausea oxycodone immediate release mg po q8h prn pain vitamin d unit po daily senna mg po daily docusate sodium mg po daily polyethylene glycol g po daily prn constipation discharge medications acyclovir mg po q12h docusate sodium mg po daily ciprofloxacin hcl mg po q12h start for days lorazepam mg po q8h prn nausea insomnia anxiety ondansetron mg po q8h prn nausea oxycodone immediate release mg po q8h prn pain polyethylene glycol g po daily prn constipation senna mg po daily vitamin d unit po daily filgrastim mcg sc q24h discharge disposition home discharge diagnosis multiple myeloma discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted for high dose cytoxan for stem cell mobilization please follow the instructions given to you by your nurse in brief this includes taking ciprofloxacin antibiotic and neupogen injections until you are told to stop you also had low sodium levels this was most likely due to a side effect from the chemotherapy and nausea you improved with time salt tablets and fluid restriction you do not have to be on any further restrictions followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies tree nut bactrim attending chief complaint auto transplant with melphalan prep major surgical or invasive procedure cvc placement cvc removal history of present illness year old male with multiple myeloma and known compression fractures s p cycles rvd now admitted for autologous transplant w melphalan prep past medical history oncologic history per atrius records was seen with mid thoracic back pain of weeks duration this was worse with walking or carrying his backpack to work noted dyspnea with exertion but no angina or shortness of breath at rest had no lower extremity weakness nor parethesis and no bowel or bladder dysfunction had plain films of this thoracic spine which showed dextroscoliosis centered at t7 subtle loss of height of the right side of the superior endplate of t7 of indeterminate age scattered endplate degenerative spurs was advised to take ibuprofen had a thoracic spine mri this showed multiple compression fractures the most severe at t7 without definite paraspinal or bone marrow edema to suggest acute fractures the visualized bone marrow signal intensity is diffusely abnormal with increased in stir signal which could be related to hematopoietic marrow hyperplasia or an infiltrative process slight retropulsion of fragments at the superior aspect of t7 indents the spinal cord minimally dorsally the subarachnoid space is widely patent rostral to this level there is a small hydromyelia likely secondary to the slight mass effect on the spinal cord was seen by dr the service and started on tramadol mg every hr as needed but has not taken this medication had labs obtained these showed cbc with wbc of hemoglobin hct plts anc esr retic cr na calcium total protein alb pth lfts normal ferritin and ig g of his iga and igm were both free kappa lambda light chains were for a ratio bone marrow bx performed by dr of and showed that the bone marrow biopsy was extensively infiltrated with plasma cells which occupied about of the marrow seen the aspirate showed about plasma cells plasma cells were kappa restricted cytogenetics demonstrated an abnormal x y add q13 add q25 der t q21 p11 add p11 fish was positive for gain of chromosomes and and extra copy of q there was no evidence of rearrangement of the igh gene deletion q monosomy deletion of tp53 or monosomy and was given dexamethasone mg a day x days was admitted to the with increased in his back pain had mris of his spine which demonstrated extensive involvement by myeloma as well as disc bulges but no evidence of epidural disease had t5 t7 compression fractures was seen by dr orthopedics and was given tlso brace to use while awake received pamidronate mg x dose on developed one temperature to on and then became neutropenic was treated empirically with cefepime then transitioned to levaquin once his wbc improved had negative cultures and no further temps had a chest ct which showed no pneumonia the bones were abnormal consistent with diagnosis of myeloma started velcade dose of mg m2 and dexamethasone mg on and then received c1d5 on with velcade dose reduced to mg m2 for his low wbc and dexamethasone mg po developed increased lfts ast and alt and had a liver ultrasound which was negative as were hepatitis serologies was told to hold acetaminophen and his lfts trended downward by the time of discharge at the time of discharge on was told to start revlimid which did on and asa mg a day was given additional days of levaquin to complete an day course of antibiotics was given tramadol and oxycodone for pain control but used these minimally during his final days of admission was cleared by to go home and not to a rehab facility additional evaluation at the included a negative upep and a skeletal series with possible small lytic lesions in humeri and skull but no other worrisome findings outside of the spine was transfused one unit of prbcs started c2 rvd developed a rash on bactrim during cycle after about days was switched to atovoquone zometa started c3 rvd started c4 rvd zometa hd cytoxan started neupogen shots for collection at total of million cd34 cells were collected past medical history lbp past surgical history tonsillectomy eye surgery for lazy eye right hand surgery social history family history siblings brother with soft tissue sarcoma on knee mother no known history of cancer or blood disorders father no known history of cancer or blood disorders still alive year old aunts no known history of cancer or blood disorders uncles no known history of cancer or blood disorders maternal grandmother no known history of cancer or blood disorders died of unknown type maternal grandfather no known history of cancer or blood disorders lived to paternal grandmother no known history of cancer or blood disorders paternal grandfather no known history of cancer or blood disorders children no known history of cancer or blood disorders physical exam admission physical exam ecog vs tc ra weight 7lbs pain gen pleasant and cooperative well appearing heent perrl anicteric sclerae oropharynx clear without erythema oral ulcerative lesions or thrush neck supple without thyromegaly or adenopathy lymphatics no cervical supraclavicular infraclavicular or axillary adenopathy cv regular rate and rhythm normal s1 s2 no s3 s4 no murmurs rubs or gallops lungs non labored clear to auscultation bilaterally without rhonchi rales or wheezes abdomen soft nontender nondistended normoactive bowel sounds throughout no hepatosplenomegaly skin warm dry and intact no new rashes or lesions ms no pain on palpation to spine or parasacral region extremities no ble edema discharge physical exam ecog vs tc ra i o own bm x pain gen nad appear anxious but well appearing heent perrl anicteric sclera oropharynx clear without erythema oral ulcerative lesions or thrush neck supple without thyromegaly or adenopathy lymphatics no cervical supraclavicular infraclavicular or axillary adenopathy cv regular rate and rhythm normal s1 s2 no s3 s4 no murmurs rubs or gallops lungs non labored clear to auscultation bilaterally without rhonchi rales or wheezes abdomen soft nontender nondistended normoactive bowel sounds throughout no hepatosplenomegaly skin dry unable to assess scrotum patient reports pruritus improving dime size macular rash on rlq unchanged no erythema or pain otherwise no new lesions or rashes ms no pain on palpation to spine or parasacral region extremities no upper or lower extremity edema line r cvc removed 2x2 gauze and tegaderm applied on site no pain or discharge pertinent results admission labs 10pm plt count 10pm neuts lymphs monos eos basos im absneut abslymp absmono abseos absbaso 10pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 10pm tot prot albumin globulin calcium phosphate magnesium uric acid 10pm alt sgpt ast sgot ld ldh alk phos tot bili 10pm urea n creat sodium potassium chloride total co2 anion gap 10pm glucose 52pm urine blood neg nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg 52pm urine color yellow appear clear sp 00am plt count 00am neuts monos eos basos im absneut abslymp absmono abseos absbaso 00am wbc rbc hgb hct mcv mch mchc rdw rdwsd 00am albumin calcium phosphate magnesium 00am alt sgpt ast sgot ld ldh alk phos tot bili 00am glucose urea n creat sodium potassium chloride total co2 anion gap discharge labs 12am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 12am blood neuts bands lymphs monos eos baso atyps metas myelos absneut abslymp absmono abseos absbaso 12am blood hypochr normal anisocy poiklo macrocy microcy polychr spheroc occasional ovalocy schisto stipple occasional tear dr occasional 12am blood plt smr low plt 12am blood glucose urean creat na k cl hco3 angap 12am blood alt ast ld ldh alkphos totbili 12am blood albumin calcium phos mg imaging cvc placement cxr impression in comparison with the study of there has been placement of a right subclavian catheter that extends to the mid portion of the svc no evidence of pneumothorax or interval change no pneumonia or vascular congestion cxr impression right subclavian central line unchanged in position lung volumes remain slightly diminished with streaky patchy opacities in the bases suggestive of atelectasis or scarring no developing airspace consolidation is seen to suggest pneumonia no pulmonary edema old right sided rib fracture stable cardiac and mediastinal contours brief hospital course assessment and plan year old male with multiple myeloma s p cycles rvd now admitted for autologous transplant w melphalan prep d diarrhea acute onset evening no abdominal cramping or fever but has had low grade temps which also have improved none 72hrs etiology likely due to chemotherapy melphalan but obtained sample to r o c diff which was negative initiated imodium atc changed to bid dosing on and further changed to prn on due to improvement stooling times daily more formed cvc discomfort reported pain likely from line placement post procedure resolved after several days and did not require oxycodone for pain management multiple myeloma his presentation was notable for a history of worsening back pain for month which when worked up by mri demonstrated multiple compression fractures and a bm signal intensity c f myeloma bm biopsy on demonstrated infiltrate with plasma cells c w with a dx of stage iii igg 7g dl and advanced lytic lesions iss stage iii beta 5mg dl was started on rvd by dr on and completed cycles w o major complications underwent hd cytoxan on and stem cell collection on and collecting million cd34 now presents for auto transplant w melphalan prep d0 melphalan mg iv q24h on days and and mg m2 cryotherapy po unit q24h on days and furosemide mg iv q24h duration days antiemetics ivf protocol d neupogen started discontinued with counts recovery discontinued ciprofloxacin ppx w counts recovery scrotal itching noted to start during count nadir likely secondary to fungal infection improved with miconazole powder added benadryl cream and nystatin cream on after exacerbated itching after shower discharged w miconazole f u outpatient anorexia nausea distaste for food early during transplant etiology likely secondary to chemotherapy melphalan rec ensures patient trialing now drinking 2l of fluids on own prior to discharge solid intake much improved back pain chronic history of compression fractures at t5 t7 previously using tlso brace which was recommended by ortho but not needing now see ortho note on no acute exacerbations during hospitalization history of constipation attributed to rvd cycles and opioids use although using sparingly now held stool regimen on admission as expect diarrhea w chemotherapy initiation see above infectious prophylaxis pcp to bactrim defer to outpatient provider for another pcp ppx hsv vzv acyclovir bid prophylaxes access r cvc placed removed prior to discharge fen low bacteria diet pain control oxycodone prn contact wife spouse disposition discharged with follow up appointment on with dr code status full medications on admission the preadmission medication list is accurate and complete acyclovir mg po q12h docusate sodium mg po daily lorazepam mg po q6h prn nausea insomnia anxiety ondansetron mg po q8h prn nausea oxycodone immediate release mg po q6h prn pain polyethylene glycol g po daily prn constipation senna mg po daily vitamin d unit po daily discharge medications acyclovir mg po q12h rx acyclovir mg tablet s by mouth q12hrs disp tablet refills lorazepam mg po q6h prn nausea insomnia anxiety rx lorazepam mg by mouth every hours disp tablet refills oxycodone immediate release mg po q6h prn pain rx oxycodone mg tablet s by mouth every 6hrs disp tablet refills vitamin d unit po daily rx ergocalciferol vitamin d2 unit one half tablet s by mouth daily disp tablet refills senna mg po daily prn constipation hold if you have diarrhea rx sennosides mg tab by mouth daily disp tablet refills polyethylene glycol g po daily prn constipation hold if you have diarrhea rx polyethylene glycol gram powder s by mouth daily disp packet refills ondansetron mg po q8h prn nausea rx ondansetron mg tablet s by mouth every hours disp tablet refills docusate sodium mg po daily prn constipation hold if you have diarrhea rx docusate sodium mg capsule s by mouth daily disp capsule refills miconazole cream appl tp tid rx miconazole nitrate application three times a day refills atovaquone suspension mg po daily will let you know when to start taking this medication again discharge disposition home discharge diagnosis multiple myeloma discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr you were admitted for an autologous stem cell transplant you developed nausea diarrhea and loss of appetite while you were admitted these are common side effects after transplant and your symptoms continue to improve your nausea medications are as follows zofran ativan you will continue to take acyclovir to prevent infection your outpatient provider let you know when to restart your atovaquone please take your temperature twice a day and call us if it goes above please be sure to drink at least 2l 64oz of fluid daily call if you are unable to do so or if you have worsening nausea or watery stools it has been a pleasure taking care of you followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies no known allergies adverse drug reactions attending chief complaint hypoxic and hypercarbic respiratory failure deep vein thromboses major surgical or invasive procedure none history of present illness y o f with atrial fibrillation on warfarin pe ckd iii pvd multinodular goiter s p biopsy w possible follicular neoplasm in who was sent to ed after being found to have l jugular and subclavian venous thrombosis despite therapeutic inr on warfarin patient found to have airway stenosis on ct imaging and s s of hypercarbic respiratory failure w abg consistent w acute on chronic hypercapnic respiratory failure sent to icu for monitoring and further workup past medical history t2dm hba1c in diet controlled hld ckd iii pvd oa iron deficiency anemia paroxysmal atrial fibrillation pulmonary embolism stroke diverticulosis goiter nontoxic multinodular aaa cm in no further eval cholelithiasis obesity lung nodules as above neurogenic bladder prolonged qt social history family history mother aunt and uncle all had chf unknown cause no known hx of cad in her family daughter with heart arrhythmia on amiodarone physical exam admission physical exam general patient pleasant and cooperative w exam and aaox3 falls asleep intermittently during exam heent sclera anicteric w evidence of slight proptosis mmm oropharynx clear neck large multinodular goiter on exam lungs clear to auscultation bilaterally no stridor at the throat no wheezes rales rhonchi cv irregularly irregular rate and rhythm normal s1 s2 sem loudest at the mitral valve no rubs gallops abd soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses left upper extremity w increased edema versus right skin no visible rashes upper lower extremities neuro as noted above patient sleepy during exam discharge physical exam vital signs on 1l general patient pleasant and cooperative w exam and aaox3 heent sclera anicteric w evidence of slight proptosis mmm oropharynx clear neck large multinodular goiter on exam lungs clear to auscultation bilaterally no stridor at the throat no wheezes rales rhonchi cv irregularly irregular rate and rhythm normal s1 s2 sem loudest at apex no rubs gallops abd soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses left upper extremity w increased edema versus right skin no visible rashes upper lower extremities neuro a o x pertinent results admission labs 05am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 05am blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 05am blood ptt 05am blood glucose urean creat na k cl hco3 angap 05am blood calcium phos mg 51pm blood tsh 51pm blood t4 52am blood type art po2 pco2 ph caltco2 base xs 56pm blood lactate other pertinent discharge labs 53pm blood cardiolipin antibodies igg igm negative 05am blood triglyc 51pm blood tsh 51pm blood t4 53pm blood totprot 53pm blood lupus neg 53pm blood thrombn 40pm blood ipt done discharge labs 40am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 40am blood ptt 40am blood glucose urean creat na k cl hco3 angap imaging lenis no evidence of deep venous thrombosis in the left lower extremity veins ct chest w and wout no evidence of pulmonary embolism or acute aortic abnormality multiple pulmonary nodules the largest of which measures mm if clinically indicated follow up chest ct is suggested at months if there is no change a second follow up in months and then at months is recommended if there is no change dilated main pulmonary artery likely reflective of pulmonary arterial hypertension markedly enlarged thyroid gland with mediastinal extension and severe narrowing of the trachea mild centrilobular emphysema cxr moderate pulmonary congestion and mild interstitial edema is increased moderate right pleural effusion is new and moderate left basilar atelectasis is increased since consistent with acute chf exacerbation large goiter unchanged ankle xr findings no acute fracture or dislocation is detected about the left ankle there is minimal spurring about the distal tibia but no other evidence of tibiotalar joint osteoarthritis the mortise joint is congruent without talar dome ocd there is prominent enthesophytic spurring along the posterior and inferior calcaneus an ovoid density projects inferior to the fibula measures mm of unclear etiology potentially sequelae of prior trauma differential diagnosis could include a early left focus hydroxyapatite or calcified lymph node no suspicious lytic or sclerotic lesion is identified vascular calcifications are noted ct abdomen no evidence of malignancy or metastatic disease within the abdomen or pelvis although residual high density oral contrast and associated artifact moderately limits evaluation of the large bowel and pelvis cholelithiasis without evidence of cholecystitis intrahepatic and extrahepatic biliary dilation which may represent previous gallstone passage extensive atherosclerosis and infrarenal abdominal aortic ectasia measuring maximally mm diverticulosis brief hospital course y o f with atrial fibrillation on warfarin pe ckd iii pvd multinodular goiter s p biopsy w possible follicular neoplasm in who was sent to ed after being found to have l jugular and subclavian venous thrombosis despite therapeutic inr on warfarin hypoxemia and hypercapnic respiratory failure acute on chronic patient w new o2 requirement hx of osa and abg was consistent with acute on chronic respiratory failure likely the patient s stenosis of her airway from large goiter contributing also may have undiagnosed copd given emphysematous changes on her ct scan along with untreated osa her elevated bicarbonate is suggestive of a chronic process she was transferred to the icu on for monitoring w continuous o2 due to concerns about airway compression and increasing oxygen requirement shortly after her admission ent was consulted on for evaluation of any airway compromise and did not feel that any intervention was warranted she did not demonstrate any respiratory distress at any time during her hospital stay she was transferred to the floor on the and had continuous o2 monitoring she also continued to use bipap with good effect at night bipap settings were epap ipap o2 flow lue dvts patient w new onset dvts despite therapeutic warfarin this is concerning for a coagulopathy it is unclear if this is inherited or acquired perhaps in the setting of malignancy no clear provoking symptoms ct abdomen pelvis was negative for overt malignancy or metastases imaging did show pulmonary nodules that will need to be followed up with repeat imaging also there is concern for malignancy related to her multinodular thyroid she is scheduled to follow up with her endocrinologist regarding this she was placed on enoxaparin mg q12hr per hematology recommendations hematology oncology was following her throughout admission as well gout patient had some left foot ankle pain which impaired her ability to walk it improved after colchicine administration xray of left foot was negative atrial fibrillation has chronic atrial fibrillation and warfarin was discontinued as she developed upper extremity dvts with therapeutic inr lovenox was initiated amiodarone was at first discontinued in the icu and then restarted on the floor she was discharged on her home dose of daily her pr interval was and she was not considered a good candidate for a beta blocker while in house coronary artery disease stable continued atorvastatin aspirin hypertension stable continued home amlodipine lisinopril thyroid disease patient w large goiter and questionable effect on trachea followed by endocrinology ip and ent at will consider intervention pending whether there is malignancy within goiter and overall patient prognosis methimazole was continued thyroglobulin pending at discharge abd pelvic ct without evidence of malignancy mgus monoclonal igg kappa represents only of total protein the rest of it and iga are polyclonal free kappa and lambda light chains both slightly elevated not worrisome for myeloma no further evaluation needed transitional issues she was followed by hem onc atrius as inpatient pcp can refer her to dr heme for further follow up if deemed appropriate for the pcp ip can offer her a joint procedure with ent regarding her large multinodular goiter and its impingement on the trachea when it is clear whether there is malignancy present or not and what the overall prognosis of patient is they can certainly stent her trachea if it starts to compromise her airway if that is within the patient goals of care an appointment in interventional pulmonology compromised clinic is being made for her at to follow up this issue multiple pulmonary nodules the largest of which measures mm if clinically indicated follow up chest ct is suggested at months if there is no change a second follow up in months and then at months is recommended if there is no change repeat fna in weeks with endocrinology thyroglobulin pending at discharge nightly bipap epap ipap o2 flow patient started on lovenox mg sc bid for ue dvt which occurred while on warfarin consider starting allopurinol for prevention of gout hcp code full confirmed medications on admission the preadmission medication list is accurate and complete amiodarone mg po daily amlodipine mg po daily aspirin mg po daily atorvastatin mg po qpm calcium carbonate mg po daily ferrous sulfate mg po daily lisinopril mg po daily multivitamins tab po daily md to order daily dose po daily16 methimazole mg po daily discharge medications amiodarone mg po daily amlodipine mg po daily aspirin mg po daily atorvastatin mg po qpm calcium carbonate mg po daily lisinopril mg po daily methimazole mg po daily multivitamins tab po daily enoxaparin sodium mg sc q12h start today first dose next routine administration time ferrous sulfate mg po daily discharge disposition extended care facility discharge diagnosis primary diagnosis deep vein thrombosis hypoxemic and hypercapnic respiratory failure secondary gout flare secondary diagnosis atrial fibrillation coronary artery disease hypertension multinodular thyroid discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms you were admitted to for swollen arms and you were found to have clots in your arms even though you were on coumadin your medication coumadin was changed to lovenox mg twice a day you were also started on bipap at night to help your breathing at night you should continue to use this you were also treated for a gout flare and your foot feels improved please keep your appointments with your urologist endocrinologist and primary care physician you will also need to follow up with the lung doctors who were following you as an inpatient it was a pleasure taking part in your care your team followup instructions

name unit no admission date discharge date date of birth sex f service surgery allergies no known allergies adverse drug reactions attending chief complaint toxic large substernal multinodular goiter major surgical or invasive procedure resection of left substernal goiter and resection of medial aspect right lobe history of present illness this is a year old woman who lady presented with a chronically toxic multinodular goiter that was however enlarging causing tracheal deviation and stenosis fna of a nodule on the left side also was suspicious for papillary cancer consequently we arranged to do a total thyroidectomy but the possibility of a staged operation had been raised preoperatively past medical history toxic multinodular goiter causing tracheal stenosis and deviation mild mitral regurg moderate pulm htn hld dm2 paroxysmal afib on lovenox dvt l arm now on lovenox pulm embolism in htn pad s p lower extremity bypass graft copd gout prior stroke possibly with neurogenic bladder now s p suprapubic catheter ongoing tobacco use as of psh cataracts fem pop bpg hysterectomy suprapubic urinary catheter social history family history mother aunt and uncle all had chf unknown cause no known hx of cad in her family daughter with heart arrhythmia on amiodarone physical exam general aa o pleasant no distress cardiac irreg irreg rate and rhythm normal s1 s2 pulm clear no stridor abd soft nt nd inc neck soft incision c d i no erythema drainage ext warm well perfused no edema brief hospital course with massive multinodular goiter with fna suspicious for papillary thyroid cancer she presented to on and underwent left thyroid lobectomy initially postoperatively she was hypertensive and received iv labetalol and responded appropriately she was transferred to the surgical ward overnight for observation postoperatively she was able to tolerate regular diet ambulate and achieve adequate pain control on oral medications her surgical site remained c d i and without evidence of hematoma or drainage once she met the appropriate criteria she was discharged home on pod1 with scheduled follow up with dr postoperative care she was given instructions on wound care as well as symptoms of complications to look out for of which she expressed understanding medications on admission amlodipine qam atorvastatin qhs lovenox 80mg sq qam lisinopril qhs methimazole qam asa calcium vitd qd iron mvi discharge medications acetaminophen mg po q6h amlodipine mg po daily atorvastatin mg po qpm lisinopril mg po daily aspirin mg po daily please restart your aspirin hours after surgery on enoxaparin sodium mg sc qd start tomorrow first dose first routine administration time please restart your lovenox hours after your surgery discharge disposition home discharge diagnosis toxic multinodular goiter discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear ms you were admitted to the inpatient general surgery unit after your left thyroid lobectomy you have adequate pain control and have tolerated a regular diet and may return home to continue your recovery monitor for signs and symptoms of low calcium such as numbness or tingling around mouth fingertips or muscle cramps in your legs if you experience any of these signs or symptoms please call dr for advice or if you have severe symptoms go to the emergency room please note that your methimazole has been discontinued you may restart your aspirin and lovenox on hours after your surgery you may take acetaminophen tylenol as directed but do not exceed mg in one day please get plenty of rest continue to walk several times per day and drink adequate amounts of fluids please call your surgeon or go to the emergency department if you have increased pain swelling redness or drainage from the incision site you may shower and wash incisions with a mild soap and warm water avoid swimming and baths until cleared by your surgeon gently pat the area dry you have a neck incision with steri strips in place do not remove they will fall off on their own thank you for allowing us to participate in your care your team followup instructions

name unit no admission date discharge date date of birth sex f service surgery allergies no known allergies adverse drug reactions attending chief complaint status post left thyroid lobectomy with follicular thyroid carcinoma major surgical or invasive procedure completion right thyroidectomy history of present illness this elderly patient has undergone resection of a very large left substernal goiter last year and the pathology showed widely invasive follicular carcinoma and completion was recommended past medical history pmh toxic multinodular goiter causing tracheal stenosis and deviation mild mitral regurg moderate pulm htn hld dm2 paroxysmal afib on lovenox dvt l arm now on lovenox pulm embolism in s p lower extremity bypass graft copd gout prior stroke possibly with neurogenic bladder now s p suprapubic catheter ongoing tobacco use as of social history family history mother aunt and uncle all had chf unknown cause no known hx of cad in her family daughter with heart arrhythmia physical exam gen a o nad heent no scleral icterus mucus membranes moist neck incision w staples c d i no erythema ecchymosis or drainage cv rrr no m g r pulm clear to auscultation b l no w r r abd soft nondistended nontender no rebound or guarding gu suprapubic catheter w clear yellow urine ext no edema warm and well perfused pertinent results 50am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 50am blood glucose urean creat na k cl hco3 angap 50am blood calcium phos mg brief hospital course ms is a f with hx of multinodular goiter and follicular thyroid carcinoma s p prior left thyroid lobectomy and resection of medial aspect of right lobe now s p complete right thyroidectomy surgery was uncomplicated reader is referred to operative report for details of surgery she was admitted overnight for observation following admission her calcium level was monitored and was found to be appropriate postoperatively she had adequate urine output via her suprapubic catheter her diet was advanced and well tolerated she ambulated and was able to achieve adequate pain control on oral medications her surgical site remained c d i and without evidence of hematoma or drainage once she met the appropriate criteria she was discharged home on pod1 with scheduled follow up with dr postoperative care additionally thyroid hormone replacement calcium and vitamin d supplementation were added to her medication regimen as well as pain medication in regards to her anticoagulation for h o afib dvt which was held patient has been instructed to restart lovenox on she was discharged home on pod with detailed follow up instructions and verbalized good understanding medications on admission medications amlodipine mg po daily atorvastatin mg po qpm lisinopril mg po daily aspirin mg po daily enoxaparin sodium mg sc qd hctz 5mg daily methimazole 25mg daily metoprolol xr qdaily ferrous sulfate daily mvi daily calcium d mg mg unit tablet discharge medications acetaminophen mg po tid calcitriol mcg po daily rx calcitriol mcg capsule s by mouth once a day disp capsule refills levothyroxine sodium mcg po daily rx levothyroxine mcg tablet s by mouth once a day disp tablet refills os cal d3 calcium carbonate vitamin d3 mg 250mg unit oral qid amlodipine mg po daily aspirin mg po daily atorvastatin mg po qpm docusate sodium mg po bid enoxaparin sodium mg sc daily start tomorrow first dose first routine administration time ferrous sulfate mg po daily hydrochlorothiazide mg po daily lisinopril mg po daily metoprolol succinate xl mg po daily multivitamins tab po daily senna mg po hs vitamin d unit po daily discharge disposition home discharge diagnosis status post left thyroid lobectomy with follicular thyroid carcinoma discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms it was a pleasure being involved in your care at you were admitted to the inpatient general surgery unit after your completion thyroidectomy you have adequate pain control and have tolerated a regular diet and may return home to continue your recovery you will be discharged home on thyroid hormone replacement calcium and vitamin d supplement please take as prescribed for your calcium supplement please purchase oscal chewable tablets are acceptable over the counter at the pharmacy and take tablet four times a day please go to any lab on before pm and have your calcium level drawn if there is a need to change your calcium dosage your endocrinologist will give you further instructions please monitor for signs and symptoms of low calcium such as numbness or tingling around mouth fingertips or muscle cramps in your legs if you experience any of these signs or symptoms please call dr for advice or if you have severe symptoms go to the emergency room please restart your lovenox on thurs as prescribed you may restart all regular home medications and take any new medications as prescribed you will be given a prescription for narcotic pain medication take as prescribed you may take acetaminophen tylenol as directed but do not exceed mg in one day please get plenty of rest continue to walk several times per day and drink adequate amounts of fluids please call your surgeon or go to the emergency department if you have increased pain swelling redness or drainage from the incision site you may shower and wash incisions with a mild soap and warm water avoid swimming and baths until cleared by your surgeon gently pat the area dry your neck incision has been closed with staples please call the office and schedule an appointment for staples to be removed by thank you for allowing us to participate in your care your care team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies no known allergies adverse drug reactions attending chief complaint complete heart block major surgical or invasive procedure none history of present illness ms is an female with history of a fib on coumadin chronic kidney disease copd on 2l o2 severe pulmonary hypertension who is presenting as a transfer from for concern for 3rd degree heart block the patient was recently admitted to in for syncope she was walking through a store to buy medications for her constipation and she became lightheaded weak and she fell to the floor and hit her head she endorsed epigastric pain prior to event but no other prodrome of diaphoresis nausea or tunnel vision the event was thought to be due to pulmonary htn from chronic copd as her tte showed elevated pa pressures as well as a possible orthostatic component she was given gentle fluids and her lasix was held but resumed at a decreased dose prior to discharge she was also given prednisone 30mg po daily levaquin 250mg daily and started on albuterol nebulizers she was discharged on 2l nc with plan to get outpatient pfts she states that she has not been the same since discharge she used to be able to walk her dog around the block multiple times but in the past month she has been so short of breath she has not been able to walk her dog at all the most activity she is able to perform is chores around the house she has noticed lower extremity swelling but no orthopnea pnd nausea or vomiting she does not weigh herself as she does not have a scale but she does not think she has gained weight she manages all of her medications on her own and does not think she missed any doses the patient was cooking dinner for herself the night prior to admission when she developed a sharp chest pressure in the left side of her chest the pain progressed so she called ems she denied any palpitations shortness of breath nausea or vomiting the pain lasted about one hour when emts arrived she was bradycardic to the on arrival to her blood pressure was with a heart rate of ekg was concerning for complete heart block she had minimal response to atropine so was started on transvenous pacing without capture she was then given pushes of epinepherine then started on an epinepherine drip her lowest blood pressure was labs were notable for a creatinine of potassium of ph on the vbg of with a pco2 of and a bicarbonate of she was then given ivf boluses and started on a bicarbonate drip she was also given amp of calcium gluconate and 3mg of glucagon given concern for av nodal blockage overdose the patient was transferred to for further management of complete heart block blood pressure was on transfer and she was placed on epinepherine and norepinephrine in the ed epinephrine and norepinephrine were weaned off and she was placed on dopamine mcg kg min in the ed initial vitals were 3l nc exam notable for none documented labs notable for wbc of hgb of plt of na of k of cl of hco3 of bun cr of alt of ast of alp of tbili of vbg with lactate of studies notable for cxr with apparent opacities projecting over the right lower lung may partially be due to costochondral calcifications but cannot exclude possible lung parenchymal opacities patient was given iv drip dopamine mcg kg min cc ivf iv calcium gluconate gm on arrival to the ccu the patient endorses shortness of breath mildly improved from prior she denies any chest pain nausea vomiting palpitations dysuria urgency frequency or diarrhea she has been eating and drinking normally over the past few days in speaking with renal this morning they recommended 1l of nabicarb for his acidosis past medical history cardiac history type diabetes hypertension dyslipidemia atrial fibrillation hfpef other pmh ckd stage iii copd social history family history father cause cva cerebral vascular accident mother cause colon cancer daughter age cause diabetes mellitus son age cause syndrome son age cause hydrocephalus physical exam admission exam vs reviewed in metavision general well developed well nourished in nad oriented x3 mood affect appropriate heent normocephalic atraumatic sclera anicteric perrl eomi neck supple jvp at cm at degrees cardiac normal rate regular rhythm no murmurs rubs or gallops lungs no chest wall deformities or tenderness scattered wheezes throughout both lung fields abdomen soft non tender non distended no palpable hepatomegaly or splenomegaly extremities warm well perfused pitting edema of both lower extremities bilaterally skin no significant lesions or rashes pulses distal pulses palpable and symmetric discharge exam hr data last updated temp tm bp hr rr o2 sat o2 delivery 3l wt lb kg general well developed well nourished in nad oriented x3 mood affect appropriate cardiac rrr no murmurs rubs or gallops lungs decreased breath sounds no wheezing no increased wob or use of accessory muscles abdomen soft ntnd no palpable hepatomegaly or splenomegaly extremities pitting edema of both lower extremities bilaterally to mid shin pulses distal pulses palpable and symmetric neuro alert conversant no gross focal deficits pertinent results admission labs 59pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 59pm blood neuts lymphs monos eos baso nrbc im absneut abslymp absmono abseos absbaso 59pm blood ptt 59pm blood alt ast ck cpk alkphos totbili 59pm blood albumin interval labs 05am blood po2 pco2 ph caltco2 base xs comment green top 46am blood po2 pco2 ph caltco2 base xs comment green top 37am blood cortsol 59pm blood tsh 55am blood caltibc ferritn trf 59pm blood ctropnt 37am blood ck mb ctropnt microbiology am blood culture blood culture routine preliminary staphylococcus coagulase negative isolated from only one set in the previous five days blood culture no growth urine culture no growth final mrsa swab pending blood culture no growth to date pending blood culture no growth to date pending imaging tte the left atrial volume index is normal the right atrium is mildly enlarged there is no evidence for an atrial septal defect by 2d color doppler the estimated right atrial pressure is mmhg there is normal leftventricular wall thickness with a normal cavity size there is normal regional and global left ventricular systolic function quantitative biplane left ventricular ejection fraction is left ventricular cardiac index is depressed less than l min m2 there is no resting left ventricular outflow tract gradient diastolic parameters are indeterminate mildly dilated right ventricular cavity with moderate global free wall hypokinesis tricuspid annular plane systolic excursion tapse is depressed there is abnormal interventricular septal motion c w right ventricular pressure and volume overload the aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender the aortic arch diameter is normal with a normal descending aorta diameter the aortic valve leaflets appear structurally normal there is no aortic valve stenosis there is no aortic regurgitation the mitral valve leaflets appear structurally normal with no mitral valve prolapse there is trivial mitral regurgitation the pulmonic valve leaflets are not well seen the tricuspid valve leaflets appear structurally normal there is moderate tricuspid regurgitation there is moderate to severe pulmonary artery systolic hypertension there is no pericardial effusion impression moderate to severe pulmonary artery systolic hypertension right ventricular cavity dilation with free wall hypokinesis moderate tricuspid regurgitation renal u s study date of atrophic kidneys bilaterally no hydronephrosis small right pleural effusion cxr heart size is top normal mediastinum is stable right basal opacities are minimal and unchanged unlikely to represent infectious process but attention on the subsequent radiographs is recommended to this area no pleural effusion or pneumothorax is seen ct chest w o contrast no evidence of interstitial lung disease moderate upper lobe predominant centrilobular emphysema small bilateral pleural effusions with minor associated atelectasis coronary calcification cholelithiasis without evidence of acute cholecystitis few small lung nodules measuring up to at most mm these are very likely benign but noting emphysema may be appropriate to consider follow up chest ct for surveillance in year recommendation s follow up chest ct is recommended for surveillance of very small probably benign lung nodules in year ruqus with duplex patent hepatic vasculature no evidence for portal vein thrombosis loss of diastolic flow in the main hepatic artery is likely secondary to hepatic congestion cholelithiasis without cholecystitis small right pleural effusion v q scan findings ventilation images demonstrate irregular tracer distribution in both lung fields perfusion images demonstrate irregular tracer uptake in both lung fields worse on the left compared to the right all perfusion images are matched but less apparent than the defects noted on ventilation imaging chest x ray shows bibasilar infiltrates and pulmonary congestion impression ventilation images more apparent than perfusion images most consistent with copd airways disease no clear evidence of pulmonary thromboembolism discharge labs 19am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 19am blood 19am blood plt 19am blood glucose urean creat na k cl hco3 angap 10am blood alt ast ld ldh alkphos totbili 00am blood 37am blood ck mb ctropnt 19am blood calcium phos mg 55am blood caltibc ferritn trf 47am blood anca pnd 47am blood rheufac cntromr negative 47am blood c3 c4 47am blood hiv ab neg 55am blood vanco brief hospital course ms is an female with history of a fib on coumadin chronic kidney disease copd on 2l o2 severe pulmonary hypertension who is presenting as a transfer from for bradycardia likely due to metabolic disturbances in the setting from right sided heart failure hfpef thought related to new severe pulmonary hypertension discharge cr discharge weight lb kg discharge diuretic furosemide mg daily discharge hgb acute issues bradycardia the patient presented with bradycardia in the setting of electrolyte disturbance and acidosis as transfer from reportedly at the osh her ecg was concerning for possible atrial fibrillation w complete heart block and both atropine and transcutaneous pacing were attempted prior to transfer of note on arrival to she was noted to be in atrial fibrillation w slow ventricular response and rates sequence of causality is unclear ie if patient was bradycardic leading to decreased renal perfusion and thus an acidosis or if patient was acidotic due to renal failure or other cause leading to bradycardia however given lack of other end organ damage more likely the latter her troponins were negative so unlikely to be ischemic in etiology she is on high doses of metoprolol and diltiazem at home and denies taking more medications than prescribed on arrival the pt was briefly on a dopamine drip in this setting her metoprolol and dilitiazem were held and her metoprolol was slowly reintroduced her bradycardia resolved pulmonary hypertension the patient had evidence of volume overload with elevated jvp and lower extremity edema consistent with right sided heart failure exacerbation however with diuresis the patient became orthostatic rhc showed severe pulmonary hypertension likely group iii iso oxygen dependent copd but evaluation for other causes was recommended by pulmonary group i work up included anca ccp anti centromere pending at time of discharge c3 c4 rf anti rnp negative hiv negative she is s p ruqus with doppler for portopulmonary htn no evidence of porto pulmonary htn group iii work up was unable to acquire full pfts spirometry dlco lung volumes has appointment on a non con ct chest demonstrated emphysema regarding group iv workup a vq scan was performed without evidence of pe hfpef patient with new diagnosis of hfpef with evidence of right sided hf likely secondary to copd given elevated rv pressures on her tte right axis deviation low limb lead voltage on her ekg she is chronically on 3l but had an increased oxygen requirement intitially she was initially diuresed with iv lasix but this was ultimately held given mild tte this admission notable for rv dilation w free wall hypokinesis she was diuresed with iv lasix transitioned to torsemide held acei in the setting of received metoprolol as above continued to hold diltiazem imdur was discontinued given absence of angina continued with iv lasix lead to orthostatic hypotension and rhc was done to evaluate for volume overload pcwp was normal at and ci was normal at pa pressure was consistent for severe pulmonary hypertension as above at discharge diuretic was her home dose of furosemide 10mg po atrial fibrillation chads2vasc of on warfarin inr supratherapeutic on admission initially held diltiazem and metoprolol iso of bradycardia high doses of av nodal blocking agents suggest that she has difficult to control rates she had intermittent bouts of af w rvr to 150s while her nodal agents were being held we restarted her metoprolol and uptitrated to metoprolol tartrate 25mg q6h her home dose of metop and consolidated to 100mg succinate prior to discharge anticoagulation was continued with warfarin mg after correction of coagulopathy coagulopathy on arrival pt s inr was supratherapeutic to with prolonged ptt and decreasing platelets possibly in the setting of congestive hepatopathy vs due to changes in her po intake prior to arrival she was given po vitamin k for three days w normalization of her inr fibrinogen normal blood smear showed schistocytes warfarin was restarted as above iron deficiency anemia pt w hgb this admission required intermittent prbc her iron studies are consistent w fe deficiency anemia ferritin tibc fe stool guaiac positive but brown likely slow lower gi bleed iso supratherapeutic inr inr reversed with vitamin k and hgb stabilized she should undergo egd and a colonoscopy as an outpatient but had adamantly refused inpatient evaluation she received iv iron repletion x3 days non anion gap metabolic acidosis patient with non anion gap metabolic acidosis with respiratory acidosis bicarbonate is chronically around but ph was on presentation non anion gap metabolic acidosis likely due to renal failure from worsening heart failure or injury due to hypotensive event she required small quantities of bicarb initially before her ph normalized renal was consulted while she was inpatient and improved without intervention on ckd patient has been seen by nephrologist with workup notable for negative spep upep baseline creatinine in give exertional dyspnea lower extremity dyspnea and volume overload likely pre renal from decreased effective circulatory volume cr was on admission and improved initially with diuresis diuresis was restarted with increase in cr on discharge cr was positive blood cultures leukocytosis possible cellulitis she was briefly on vancomycin for possible gpc bactermia but given speciation as cons only in one bottle suspect this may have been contaminant she had a full infectious workup which was negative and we transitioned her to keflex to complete a day course for cellulitis chronic issues diabetes mellitus on levemir 10u sq qhs so switched to glargine 10mg qhs with sliding scale insulin while inpatient copd baseline 3l of home o2 with extensive smoking history continued advair gout continued allopurinol dose reduced to every other day in setting of worsening renal function code dnr okay to intubate contact hcp son transitional issues recommend performance of full pfts spirometry dlco lung volumes which are scheduled at on recommend follow up with a pulmonologist she preferred to see a provider closer to home as outpatient follow up in will be challenging for her to keep if possible outpatient follow up should involve a local pulmonologist at and ph specialist at she has had relatively extensive pulmonary hypertension workup however still needs pfts we have scheduled an appointment for her on at with a pulmonary hypertension specialist recommend referral to a cardiologist given her bradycardia with heart block on admission and further titration of nodal blockers few small lung nodules measuring up to at most mm these are very likely benign but noting emphysema may be appropriate to consider follow up chest ct for surveillance in year pt w iron deficiency anemia this admission w hgb her stool was guaic positive but pt did not have any brbpr or melena so suspecting slow ooze she was repleted with iv iron consider egd colonscopy as an outpatient consider transition from colesevelam to a statin consider continuing iron repletion as an outpatient diuretic management she was discharged on lasix 10mg po with notable lower extremity edema further attempts at diuresis were made during her hospital course with worsening of her kidney function absent of resolution of her edema and orthostasis inr management she was supratherapeutic with inr of on admission please continue to monitor inr closely on discharge she was ultimately continued on her home dose of mg daily reduced allopurinol to every other day dosing due to decreased crcl if cr improves can consider increasing dose monitor bp stopped ace because she was normotensive at rest and intermittently orthostatic medications on admission the preadmission medication list is accurate and complete albuterol neb soln neb ih q6h prn shortness of breath fosinopril mg oral daily levemir units bedtime fluticasone salmeterol diskus inh ih bid welchol colesevelam mg oral bid isosorbide mononitrate extended release mg po daily omeprazole mg po daily allopurinol mg po daily metoprolol succinate xl mg po daily diltiazem extended release mg po daily warfarin mg po daily16 vitamin d unit po daily aspirin mg po daily furosemide mg po daily discharge medications allopurinol mg po every other day rx allopurinol mg tablet s by mouth every other day disp tablet refills levemir units bedtime albuterol neb soln neb ih q6h prn shortness of breath aspirin mg po daily fluticasone salmeterol diskus inh ih bid furosemide mg po daily metoprolol succinate xl mg po daily omeprazole mg po daily vitamin d unit po daily warfarin mg po daily16 welchol mg oral bid discharge disposition home with service facility discharge diagnosis primary diagnosis bradycardia pulmonary hypertension secondary diagnosis atrial fibrillation 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 ms thank you for allowing us to participate in your care why was i admitted to the hospital your heart rates were extremely slow what did you do for me while i was here your heart rates were monitored closely we slowly restarted some your medications to control your heart rates you were treated with antibiotics for a possible skin infection your blood was too thin so we held a few doses of your blood thinner until it normalized you had a right heart catheterization which showed severe pulmonary hypertension so you were seen by lung doctors after you leave please take your medications as prescribed please attend any outpatient follow up appointments you have upcoming your primary care doctor refer you to a local pulmonologist we would also recommend that you follow up with a pulmonary hypertension specialist here at we have made an appointment for you see below and there are pulmonary function tests scheduled for the same day if you feel that you do not want to keep this appointment please call the clinic to cancel please work with your primary care provider to monitor your warfarin level or inr closely if the level is too high it can cause bleeding if it is too low it can increase your risk of a stroke please ask your primary care doctor to assist you in finding a pulmonologist close to your home they can help further evaluate the causes of your shortness of breath it was a pleasure participating in your care we wish you the very best sincerely your healthcare team followup instructions

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 dyspnea on exertion major surgical or invasive procedure cardioversion tee revealed no atrial thrombus successful cardioversion to sinus rhythm history of present illness hx af on coumadin s p dccv recurrence restarted on ac dm2 on insulin r bka with prosthetic joint mrsa cellulitis recent adm for stump infection htn hld chronic pain syndrome transferred to for cp and elevated troponin pt called atrius triage today with doe and cp on exertion for the past several days he had been getting this with just moving around such as when he puts on his prosthesis there was some associated lue numbness he had been diagnosed with recurrent afib on and was having his labs checked at the he was referred there for further evaluation in their ed initial vs were f ra labs there were significant for wbc trop cr and inr for reported afib with rvr he received iv diltiazem he was also given asa and lovenox per report he was transferred to for further cardiology evaluation in the ed initial vitals were ra ekg was read as afib qwave iii old no ste cwp cta chest no evidence of pulmonary embolism or aortic abnormality labs studies notable for wbc bun cr at baseline trop ptt inr patient was given 2l ns and morphine 5mg iv x1 vitals on transfer ra on the floor pt reports that he had a stress echo through the on orders appear through atrius system but not the results he confirms that he s been having 1wk of l parasternal cp with associated shoulder pain l arm numbness and sob with slight exertion such as placing removing his prosthetic he uses a motorized wheelchair to get around the pain is not associated with meals is not pleuritic he has felt hot but not feverish nor has had chills he has had occ palpitations there has been no cough congestion post nasal drip wheeze abdominal pain n v d incontinence of urine past medical history pmh neuropathy insomnia hypercholesteremia hypertension type ii diabetes mellitus with neurological manifestations chronic pain syndrome pain medication agreement adenomatous colon polyp s p r bka below knee amputation unilateral diabetic ulcer of left foot mrsa cellulitis episode of afib resolved with cardioversion psh r bka i d of wound above r bka at bedside l shoulder surgery open appendectomy pediatric tonsillectomy pediatric social history family history mother with cad in s p 3v cabg passed from cancer physical exam admission exam physical exam vs t bp hr rr o2 sat ra general well appearing middle aged male nad heent ncat eomi perrla anicteric sclera clear op mmm no lad neck supple with jvp of 7cm cardiac irregularly irregular no r g m lungs ctab abdomen obese soft nt nd bs extremities r bka w o lesions l foot without ulcers few open skin cuts skin multiple tattoos on upper body extremity findings as above discharge exam vs t bp hr rr o2 sat ra tele sinus rhythm last hours i o weight today 7kg on general well appearing middle aged male nad heent ncat eomi anicteric sclera clear op mmm no lad neck supple with jvp of 7cm cardiac rrr no m r g lungs ctab abdomen obese soft nt nd bs extremities r bka w o lesions l foot without ulcers few open skin cuts skin multiple tattoos on upper body pulses l dp pulse pertinent results admission labs 05pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 05pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 05pm blood plt 05pm blood glucose urean creat na k cl hco3 angap 05pm blood ck cpk 50am blood alt ast alkphos totbili 05pm blood ctropnt 20pm blood ctropnt 50am blood ck mb ctropnt 50am blood albumin calcium phos microbiology urine culture no growth blood culture no growth imaging cta chest impression no evidence of pulmonary embolism or aortic abnormality tte the left atrium is normal in size there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef regional left ventricular wall motion is probably normal diastolic function could not be assessed right ventricular chamber size and free wall motion are normal the number of aortic valve leaflets cannot be determined there is no aortic valve stenosis no aortic regurgitation is seen the mitral valve leaflets are structurally normal no mitral regurgitation is seen the estimated pulmonary artery systolic pressure is normal there is an anterior space which most likely represents a prominent fat pad compared with the report of the prior study images unavailable for review of the findings are probably similar tee no spontaneous echo contrast or thrombus is seen in the body of the left atrium left atrial appendage or the body of the right atrium right atrial appendage there is a small pfo visualized by color flow doppler imaging overall left ventricular systolic function is normal lvef right ventricular chamber size and free wall motion are normal there are simple atheroma in the ascending aorta and the descending thoracic aorta the aortic valve leaflets appear structurally normal with good leaflet excursion no masses or vegetations are seen on the aortic valve no aortic regurgitation is seen the mitral valve leaflets are structurally normal no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen the pulmonary artery systolic pressure could not be determined no vegetation mass is seen on the pulmonic valve there is no pericardial effusion impression no spontaneous echo contrast or thrombus identified normal biventricular systolic function mild mitral regurgitation small pfo procedures cardioversion impression successful electrical cardioversion of atrial fibrillation to sinus rhythm discharge labs 52am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 52am blood plt 52am blood ptt 52am blood glucose urean creat na k cl hco3 angap 52am blood calcium phos mg hx af on coumadin s p dccv recurrence restarted on ac dm2 on insulin r bka with prosthetic joint mrsa cellulitis htn hld chronic pain syndrome transferred to for chest pain worsening dyspnea on exertion and elevated troponin concerning for nstemi nstemi patient presented with chest pain in setting of elevated troponin concerning for type i nstemi however patient had stress echo at on which showed no evidence of ischemia patient in atrial fibrillation with intermittent rvr throughout admission so troponin elevation felt to be secondary to type i nstemi in setting of demand troponin stabilized and then downtrended patient underwent tee on which showed no thrombus and he was subsequently cardioverted he remained in sinus rhythm for the remainder of hospitalization patient s warfarin discontinued and he was placed on rivaroxaban post cardioversion he was discharged to home with cardiology follow up atrial fibrillation patient in atrial fibrillation with rates in 100s during admission given negative stress echo patient s symptoms thought to be triggered by persistent atrial fibrillation patient on metoprolol xl 200mg daily for rate control and he was continued on equivalent fractionated dose his home warfarin was held prior to cardioversion and patient bridged with heparin drip he underwent successful cardioversion on and remained in sinus rhythm for the remainder of admission warfarin was not re started and patient started on rivaroxaban for anticoagulation he was discharged on rivaroxaban and metoprolol with cardiology follow up leukocytosis wbc was on admission infectious work up was negative thought to be stress response in setting of persistent atrial fibrillation leukocytosis resolved without intervention type diabetes continued on home glargine and insulin sliding scale metformin held during admission but resumed upon discharge htn continued lisinopril hld continued atorvastatin chronic pain syndrome psych continued home gabapentin oxycodone and acetaminophen urinary incontinence continued oxybutynin transitional issues medications added during this hospitalization rivaroxaban 20mg daily with dinner medications stopped during this hospitalization warfarin 2mg daily patient to follow up with cardiologist dr on who will determine length of anticoagulation patient has small cut on plantar aspect of r foot does not appear infected patient instructed to apply bacitracin and keep the wound covered pcp should follow until healed code full confirmed contact wife medications on admission the preadmission medication list is accurate and complete metformin glucophage mg po bid glargine units bedtime novolog units breakfast novolog units lunch novolog units dinner oxycodone acetaminophen 5mg 325mg tab po q4h prn pain warfarin mg po daily16 vitamin d unit po daily gabapentin mg po tid atorvastatin mg po daily lisinopril mg po daily metoprolol tartrate mg po bid nystatin unit gram topical tid urea topical bid oxybutynin chloride mg oral daily discharge medications rivaroxaban mg po dinner daily with the evening meal rx rivaroxaban mg tablet s by mouth daily disp tablet refills gabapentin mg po tid glargine units bedtime novolog units breakfast novolog units lunch novolog units dinner lisinopril mg po daily metoprolol tartrate mg po bid vitamin d unit po daily metformin glucophage mg po bid nystatin unit gram topical tid oxybutynin chloride mg oral daily oxycodone acetaminophen 5mg 325mg tab po q4h prn pain urea topical bid atorvastatin mg po daily discharge disposition home with service facility discharge diagnosis primary diagnosis atrial fibrillation with rapid ventricular response type nstemi 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 caring for you at you were admitted because of chest pain and shortness of breath our testing revealed that you did not have a heart attack your heart was found to be in an abnormal rhythm called atrial fibrillation which was the likely cause of your symptoms you underwent a cardioversion a procedure to shock your heart back into a normal rhythm the procedure was successful and you did well you were started on a medication called rivaroxaban which thins your blood and prevents clots you should continue taking this medication for one month after your discharge please stop taking warfarin you should follow up with your pcp and see appointments below we wish you all the best in your recovery sincerely your team followup instructions

name unit no admission date discharge date date of birth sex f service surgery allergies penicillins attending chief complaint abd pain nausea major surgical or invasive procedure none history of present illness w hx of afib cva on coumadin prior sbo s p ex lap w loa who now p w abd pain with questionable partial sbo passing flatus loose stools past medical history high cholesterol stroke afib on coumadin chf past surgical history s lateral r ankle ex lap loa cecal polyp removal c section x2 family history non contributory physical exam vitals hr data last updated temp tm bp hr rr o2 sat o2 delivery ra fluid balance last updated last hours total cumulative 124ml in total 124ml iv amt infused 124ml out total 0ml urine amt 0ml last hours total cumulative 124ml in total 124ml iv amt infused 124ml out total 0ml urine amt 0ml physical exam gen nad axox3 card rrr no m r g pulm no respiratory distress abd soft non tender non distended ext no edema warm well perfused pertinent results examination ct abd and pelvis with contrast findings lower chest visualized lung fields are within normal limits there is no evidence of pleural or pericardial effusion 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 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 mild cortical thinning bilaterally small cortical hypodensities bilaterally are too small to characterize otherwise 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 is a small hiatal hernia the stomach distended with air and fluid the duodenum and proximal jejunum are normal in caliber there is circumferential wall thickening involving a segment of jejunum in the left upper quadrant series image there are several loops of mildly dilated small bowel with suspected transition points in the left mid abdomen and pelvis series image these loops are distal to the segment of jejunal thickening there is fecalization in the terminal ileum but the distal bowel is otherwise normal in caliber there is no pneumoperitoneum or organized fluid collection pelvis the urinary bladder and distal ureters are unremarkable there is trace 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 mild atherosclerotic disease is noted bones multilevel degenerative changes of the lumbar spine with a similar appearance of the compression deformity involving the l2 vertebral body there is no evidence of worrisome osseous lesions or acute fracture soft tissues the abdominal and pelvic wall is within normal limits impression low grade small bowel obstruction with at least ssociated short segments of circumferential wall thickening no pneumoperitoneum or fluid collections brief hospital course w hx of afib cva on coumadin prior sbo s p ex lap w loa who now p w abd pain she was admitted to the acs service following her ct scan which was concerning for partial small bowel obstruction she was kept npo with iv fluids overnight she did well overnight on hd and continued to pass flatus and have bowel movements her abdominal pain resolved and she was given a regular diet which was well tolerated on the day of discharge the patient was tolerating a regular diet without nausea or emesis she was passing flatus and having bms her abdominal pain had resolved and she was not nauseated she was ambulating at her baseline and was deemed medically appropriate for discharge home she should follow up with her primary care physician and resume all home medications following her discharge from the hospital medications on admission lasix mg qd coumadin mg x 6x weekly mg 1x weekly alprazolam mg tid prn simvastatin 80mg dorzolamide timolol eye drops bid discharge medications dorzolamide timolol ophth drop both eyes bid acetaminophen mg po q8h prn pain mild fever alprazolam mg po tid aspirin mg po daily atenolol mg po daily folic acid mg po daily furosemide mg po daily simvastatin mg po qpm vitamin d unit po daily vits a c e b complx min lutein unit mg unit oral unknown md to order daily dose po daily16 discharge disposition home discharge diagnosis small bowel obstruction discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms you were admitted to evaluation of your abdominal pain and were diagnosed with a small bowel obstruction you are recovering well and are now ready for discharge please follow the instructions below to continue your recovery please call your doctor or nurse practitioner or return to the emergency department for any of the following you experience new chest pain pressure squeezing or tightness new or worsening cough shortness of breath or wheeze if you are vomiting and cannot keep down fluids or your medications you are getting dehydrated due to continued vomiting diarrhea or other reasons signs of dehydration include dry mouth rapid heartbeat or feeling dizzy or faint when standing you see blood or dark black material when you vomit or have a bowel movement you experience burning when you urinate have blood in your urine or experience a discharge your pain in not improving within hours or is not gone within 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 degrees fahrenheit or 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

name unit no admission date discharge date date of birth sex m service surgery allergies no known allergies adverse drug reactions attending complaint abdominal pain constipation and large bowel obstruction major surgical or invasive procedure laparotomy and total colonic resection with proximal proctectomy with end ileostomy history of present illness medicine attending admission note time pcp name address phone fax cc pain and constipation hpi the patient is a year old male with h o bpad self treated with marijuana who has never had a colonoscopy who presents with abdominal distension abdominal pain and decreased stool output no stool output x days this was initially thought to represent constpation for which meds were attempted without improvement he reports that in the past days he has not stooled and may not have had flatus he was sent for ct scan yesterday where he was told that he had new colon ca he was referred to the ed given the finding of bowel obstruction on imaging in er triage vitals ra meds given none fluids given 1l ns radiology studies abdominal ct consults called gi ercp for placement of sigmoid stent and acs review of systems constitutional as per hpi denies fevers or chills and he has had a lb intentional weight loss over the past year heent x all normal respiratory cough which he states is secondary to the air in the ed being dry cardiac x all normal gi as per hpi gu x all normal skin x all normal musculoskeletal x all normal neuro x all normal endocrine x all normal heme lymph x all normal psych x all normal all other systems negative except as noted above past medical history pmh varicose veins bipolar affective disorder psh microphlebectomy social history family history father died of metastatic melanoma at age mother is alive and lives independently at age physical exam vitals t p bp rr sao2 on ra gen nad chronically ill appearing who appears older than his stated age heent ncat anicteric mmm cv s1s2 rr no m r g resp b l ae no w c r abd no bowel sounds distended soft firm with no rebound mild tenderness with deep palpation throughout extr increased lle edema compared to r derm no rash neuro face symmetric speech fluent psych calm cooperative at discharge nad rrr ewob ab soft slightly tender ostomy pink output wnl surgical incisions clean dry and intact neuro grossly intact pertinent results 01pm lactate 50pm glucose urea n creat sodium potassium chloride total co2 anion gap 50pm estgfr using this 50pm calcium phosphate magnesium 50pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 50pm neuts monos eos basos im absneut abslymp absmono abseos absbaso 50pm plt count admission abdominal ct scan large bowel obstruction narrowing collapse of the large bowel lumen in at the site of focal apple core wall thickening in the region of the distal sigmoid rectum junction which may correspond to the known colon cancer resulting in proximal large bowel dilation with stool no free air or evidence of pneumatosis wall enhancement is normal no evidence of lymphadenopathy mm right adrenal nodule of uncertain etiology this could be further evaluated with mr or ct with adrenal protocol abdominal ct scan in atrius obstructing mass in the rectosigmoid with large and small bowel dilatation proximally adjacent involvement of the pararectal soft tissues enlarged right pararectal lymph node and mild free fluid in the pelvis small right pleural effusion cm indeterminate nodule in the right adrenal on discharge 20am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 20am blood plt 40am blood glucose urean creat na k cl hco3 angap 40am blood calcium phos mg 20am blood caltibc trf brief hospital course presented to pre op holding at on for a proctocolectomy w end ilesotomy he tolerated the procedure well without complications please see operative note for further details after a brief and uneventful stay in the pacu the patient was transferred to the floor for further post operative management on he was bolused 1l of fluid for low urine output on his foley was discontinued on he was tolerating po and voided independently on his malecot was discontinued was started on a regular diet and was started on loperamide for high ostomy output on he received ostomy teaching on his loperamide was increased for high ostomy output he also received ostomy teaching neuro the patient was alert and oriented throughout hospitalization pain was initially managed with a pca pain was very well controlled the patient was then transitioned to oral pain 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 the patient had emesis that later resolved she was then advanced to clears then to a regular diet which was tolerated id the patient s fever curves were closely watched for signs of infection of which there were none heme the patient s blood counts were closely watched for signs of bleeding of which there were none prophylaxis the patient received subcutaneous heparin and dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible on the patient was discharged to home with services at discharge he was tolerating a regular diet passing flatus stooling voiding and ambulating independently he 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 x patient knowledge deficit related to ileostomy delaying discharge no social factors contributing in delay of discharge medications on admission the preadmission medication list is accurate and complete this patient is not taking any preadmission medications discharge medications acetaminophen mg po q8h prn pain do not take over mg per day rx acetaminophen mg tablet s by mouth every eight hours disp tablet refills loperamide mg po tid ostomy output please continue to monitor ileostomy output rx loperamide mg tablet by mouth three times a day disp tablet refills oxycodone immediate release mg po q4h prn pain do not drink alcohol or drive a car while taking this medication rx oxycodone mg tablet s by mouth every four hours disp tablet refills nicotine patch mg td daily please take until and then taper to lower dose patch rx nicotine mg hour patch daily disp patch refills nicotine patch mg td daily duration days please take for two weeks after finishing 14mg patch rx nicotine mg hour patch daily disp patch refills discharge disposition home with service facility discharge diagnosis large bowel resections secondary to upper rectal cancer with impending perforation discharge condition activity status ambulatory independent level of consciousness alert and interactive mental status clear and coherent discharge instructions were admitted to the hospital after a proctocolectomy with end ilesotomy have recovered from this procedure well and are now ready to return home samples from your colon were taken and this tissue has been sent to the pathology department for analysis will receive these pathology results at your follow up appointment if there is an urgent need for the surgeon to contact regarding these results they will contact before this time have tolerated a regular diet are passing gas and your pain is controlled with pain medications by mouth may return home to finish your recovery please monitor your bowel function closely may or may not have had a bowel movement prior to your discharge which is acceptable however it is important that have a bowel movement in the next days after anesthesia it is not uncommon for patient s to have some decrease in bowel function but should not have prolonged constipation some loose stool and passing of small amounts of dark old appearing blood are expected however if notice that are passing bright red blood with bowel movements or having loose stool without improvement please call the office or go to the emergency room if the symptoms are severe if are taking narcotic pain medications there is a risk that will have some constipation please take an over the counter stool softener such as colace and if the symptoms do not improve call the office if have any of the following symptoms please call the office for advice or go to the emergency room if severe increasing abdominal distension increasing abdominal pain nausea vomiting inability to tolerate food or liquids prolonged loose stool or extended constipation have laparoscopic surgical incisions on your abdomen which are closed with internal sutures and a skin glue called dermabond these are healing well however it is important that monitor these areas for signs and symptoms 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 develop any of these symptoms or a fever may go to the emergency room if your symptoms are severe may shower pat the incisions dry with a towel do not rub the small incisions may be left open to the air if closed with steri strips little white adhesive strips instead of dermabond these will fall off over time please do not remove them please no baths or swimming for weeks after surgery unless told otherwise by your surgical team will be prescribed narcotic pain medication this medication should be taken when have pain and as needed as written on the bottle this is not a standing medication should continue to take tylenol for pain around the clock and can also take advil please do not take more than 3000mg of tylenol in hours 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 lbs for until your first post operative visit after surgery please no strenuous activity until this time unless instructed otherwise thank for allowing us to participate in your care our hope is that will have a quick return to your life and usual activities good luck have a new ileostomy the most common complication from a new ileostomy placement is dehydration the output from the stoma is stool from the small intestine and the water content is very high the stool is no longer passing through the large intestine which is where the water from the stool is reabsorbed into the body and the stool becomes formed must measure your ileostomy output for the next few weeks the output from the stoma should not be more than 1200cc or less than 500cc if find that your output has become too much or too little please call the office for advice the office nurse or nurse practitioner can recommend medications to increase or slow the ileostomy output keep yourself well hydrated if notice your ileostomy output increasing take in more electrolyte drink such as gatorade please monitor yourself for signs and symptoms of dehydration including dizziness especially upon standing weakness dry mouth headache or fatigue if notice these symptoms please call the office or return to the emergency room for evaluation if these symptoms are severe may eat a regular diet with your new ileostomy however it is a good idea to avoid fatty or spicy foods and follow diet suggestions made to by the ostomy nurses please monitor the appearance of the ostomy and stoma and care for it as instructed by the wound ostomy nurses stoma intestine that protrudes outside of your abdomen should be beefy red or pink it may ooze small amounts of blood at times when touched and this should subside with time the skin around the ostomy site should be kept clean and intact monitor the skin around the stoma for bulging or signs of infection listed above please care for the ostomy as have been instructed by the wound ostomy nurses will be able to make an appointment with the ostomy nurse in the clinic days after surgery will have a visiting nurse at home for the next few weeks helping to monitor your ostomy until are comfortable caring for it on your own followup instructions

name unit no admission date discharge date date of birth sex m service neurology allergies penicillins attending chief complaint left leg weakness and numbness s p tpa major surgical or invasive procedure iv tpa prior to admission history of present illness mr is a yo man with cll dm htn hld and right subcortical stroke in who presents s p tpa from osh for left leg numbness and weakness today he went into the bedroom to put on pajamas at pm when he sat down his left leg went numb when he stood up to pull up his pants he almost fell to the left he sat down and called he was taken to where he was given tpa at pm since receiving tpa he feels that his symptoms are unchanged in he had left face arm leg paresis and numbness due to stroke he recovered with the exception of left thigh weakness though he was still able to move his leg he walks with a cane this leg weakness numbness today felt similar to his previous stroke he has chronic right shoulder pain on neuro ros the pt denies headache loss of vision blurred vision diplopia dysarthria dysphagia lightheadedness vertigo tinnitus or hearing difficulty denies difficulties producing or comprehending speech no bowel or bladder incontinence or retention on general review of systems the pt denies recent fever or chills no night sweats or recent weight loss or gain denies cough shortness of breath denies chest pain or tightness palpitations denies nausea vomiting diarrhea constipation or abdominal pain no recent change in bowel or bladder habits no dysuria denies arthralgias or myalgias denies rash past medical history cll ppm for bradycardia stroke in htn hld dm social history family history no cancer or stroke physical exam admission exam vitals ra general awake cooperative nad heent nc at mmm neck supple no nuchal rigidity pulmonary ctabl cardiac rrr no murmurs abdomen soft nontender nondistended extremities mild edema pulses palpated neurologic mental status alert oriented x able to relate history without difficulty language is fluent with intact repetition and comprehension normal prosody there were no paraphasic errors pt was able to name both high and low frequency objects speech was not dysarthric able to follow both midline and appendicular commands attentive able to name backward without difficulty there was no evidence of neglect cranial nerves i olfaction not tested ii perrl to 2mm both directly and consentually brisk bilaterally vff to confrontation iii iv vi eomi without nystagmus normal saccades v facial sensation intact to light touch in all distributions vii no facial droop facial musculature symmetric and strength in upper and lower distributions bilaterally viii hearing intact to finger rub bilaterally ix x palate elevates symmetrically xi strength in trapezii and scm bilaterally xii tongue protrudes in midline motor normal bulk paratonia 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 r dtrs bi tri pat ach l r plantar response was extensor bilaterally pectoralis jerk was absent and crossed adductors are absent sensory left thigh and calf decreased ft and pin normal sensation in left foot mildly decreased proprioception bilaterally coordination mild intention tremor on l fnf no dysmetria on fnf normal r hks gait not tested discharge exam mental status alert oriented x language is fluent with intact repetition and comprehension normal prosody there were no paraphasic errors pt was able to name both high and low frequency objects speech was not dysarthric able to follow both midline and appendicular commands attentive with no evidence of neglect cranial nerves perrl eomi without nystagmus no facial asymmetry palate elevates symmetrically and tongue in midline motor full strength in the ue ip quad ham ta l r dtrs bi tri pat ach l r sensory left leg mild decrease sensation to light touch no dermatomal pattern pertinent results admission labs wbc rbc hgb hct plt neuts bands lymphs monos eos baso atyps myelos absneut abslymp absmono abseos absbaso ptt glucose urean creat na k cl hco3 angap alt ast alkphos totbili calcium phos mg ctropnt stox negative utox opioids ua bland stroke risk factors cholest triglyc hdl chol hd ldlcalc hba1c eag tsh t3 pnd free t4 pnd imaging cta head neck impression patent circle of patent vasculature in the neck with no evidence of internal carotid artery stenosis by nascet criteria no acute intracranial abnormality at least moderate spinal canal stenosis at c2 c3 and c3 c4 secondary to ossifications of the posterior longitudinal ligaments ct head post tpa no hemorrhagic transformation or evolving infarct noted echocardiogram the left atrium is normal in size the estimated right atrial pressure is mmhg agitated saline injected at rest but suboptimal image quality precludes adequate visualization of bubbles there is mild symmetric left ventricular hypertrophy with normal cavity size and regional global systolic function lvef there is no ventricular septal defect the aortic root is mildly dilated at the sinus level the ascending aorta is mildly dilated the aortic valve leaflets are mildly thickened but aortic stenosis is not present mild aortic regurgitation is seen the mitral valve appears structurally normal with trivial mitral regurgitation there is no mitral valve prolapse there is mild pulmonary artery systolic hypertension there is no pericardial effusion impression bubble study at rest performed but inadequate to exclude a pfo asd due to very suboptimal image quality mild symmetric left ventricular hypertrophy with preserved regional and global systolic function contrast used for better endocardial definition mild aortic regurgitation mild pulmonary artery systolic hypertension brief hospital course mr presented to osh with acute onset left leg numbness and weakness he received iv tpa and was transferred to for monitoring neuro at he was found to have proximal distal weakness of the left lower extremity with some improvement in his sensory deficit his lower extremity exam had some functional overlay and was variable from day to day he was monitored in the icu for hours without change in his examination and there was no evidence hemorrhagic transformation on his ct head the etiology of his symptoms remained unclear cta head and neck was difficult to interpret given timing of contrast possibly with a cutoff in r aca territory but there was no evidence of evolving infarct within the limits of ct on repeat scan an echo was done but was of poor quality his stroke risk factors were assessed and include dyslipidemia iddm htn obesity lipid panel revealed low ldl and hdl and elevated triglycerides with a high triglyceride to ldl ratio diabetes management is discussed below his blood pressure was in good control ranging between s s s his home aspirin was restarted and his simvastatin and fenofibrates were continued no meds were changed heme onc his outpatient oncologist recommended holding is ibrutinib for hours after tpa due to elevated bleeding risk this will be restarted as outpatient thyroid he was continued on his home levothyroxine his thyroid function tests were notable for an elevated tsh at t3 diabetes his a1c was elevated at and his metformin was initially held after contrast he was maintained on insulin glargine and sliding scale his were elevated and that was the result of giving him at bedtime when he typically has it twice a day at discharge his diabetes regimen was restarted as per his home regimen given that his blood glucose was well controlled that regiment and this was confirmed with diabetes consult team muskuloskeletal he complained of left shoulder pain with a remote hx of trauma we had a shoulder x ray that was negative and pain was well controlled on ibuprofen and vicodin which he sues at home medications on admission the preadmission medication list is accurate and complete amlodipine mg po daily brimonidine tartrate ophth drop both eyes bid divalproex extended release mg po qam divalproex extended release mg po qpm fenofibrate mg po daily fluoxetine mg po daily furosemide mg po daily gabapentin mg po tid hydrocodone acetaminophen 5mg 325mg tab po tid prn pain ibrutinib mg oral daily glargine units breakfast glargine units bedtime levothyroxine sodium mcg po daily losartan potassium mg po daily metformin glucophage mg po bid risperidone mg po daily simvastatin mg po qpm ziprasidone hydrochloride mg po bid aspirin ec mg po daily calcium carbonate mg po daily vitamin d3 cholecalciferol vitamin d3 unit oral daily senna mg po bid prn cosntipation trazodone mg po qhs discharge medications aspirin ec mg po daily divalproex extended release mg po qam divalproex extended release mg po qpm fenofibrate mg po daily gabapentin mg po tid hydrocodone acetaminophen 5mg 325mg tab po tid prn pain levothyroxine sodium mcg po daily risperidone mg po daily senna mg po bid prn cosntipation simvastatin mg po qpm ziprasidone hydrochloride mg po bid amlodipine mg po daily brimonidine tartrate ophth drop both eyes bid calcium carbonate mg po daily furosemide mg po daily ibrutinib mg oral daily losartan potassium mg po daily metformin glucophage mg po bid vitamin d3 cholecalciferol vitamin d3 unit oral daily fluoxetine mg po daily glargine units breakfast glargine units bedtime trazodone mg po qhs discharge disposition home with service facility discharge diagnosis left leg weakness discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear mr you were admitted to after being treated with a blood thinning intravenous medication called tpa for concerns of an acute stroke as you presented with worsening left leg weakness and numbness we found no stroke on repeated brain imaging the weakness and numbness has been improving you also complained of left shoulder pain for which we obtained an x ray and that was normal you should continue your home medications followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies penicillins codeine acetaminophen oxycodone attending chief complaint chest pain major surgical or invasive procedure impressions left main normal lad with mid diffuse disease lcx mild disease rca mild disease recommendations med tx history of present illness yo m with htn hld af on xarelto last dose who presented to on with chest pain and marginal trop leak he was transferred to holding area for cardiac catheterization for ongoing chest pain past medical history cll ppm for bradycardia stroke in htn hld dm social history family history no cancer or stroke physical exam admission exam vs temp afeb hr sr rr comfortable bp o2 sat 2l ecg na general lying on stretcher anxious but cooperative heent mm dry neck no lad no jvd cv rrr no m r g chest ls clear bilat abd soft nt ext no edema dp and pulses dopplerable discharge exam vs hr rr sat ra tele sinus rhythem beats svt overnight asymptomatic labs wnl ecg sb bpm labs hct plts inr bun creat na k trop ck mb mag pe general lying on stretcher anxious but cooperative neuro awake alert and oriented x3 vague but appropriate mae ambulating with cane in halls speech clear appropriate and comprehensible heent mm dry neck no lad no jvd cv rrr no m r g chest ls clear bilat abd soft nt ext no edema dp and pulses dopplerable access site without bleeding hematoma or bruit pertinent results 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 15am blood hct plt 15am blood plt 15am blood 00am blood plt 55am blood ptt 26am blood ptt 00am blood plt 15am blood urean creat na k 00am blood k 20am blood urean creat na k 00am blood glucose urean creat na k cl hco3 angap 15am blood ck cpk 15am blood ck mb ctropnt 00am blood ctropnt 30pm blood ctropnt 20am blood ctropnt 50pm blood ctropnt 00am blood ctropnt 15am blood mg brief hospital course this is a year old male with a history of dementa cva hyperlipidemia hypertension and osa transferred for cardiac catheterization following presentation to for chest pain and a mildly elevated troponin he underwent repeat catheterization and received a des to the lad post procedure he is doing well and is looking forward to being discharged his access sites were dry and intact with no erythema excess warmth bleeding or bruit noted he will be discharged home with home services and support as prior to admission with addition of services for home evaluation safety and will hopefully transition to cardiac rehab when appropriate referral discussed and given medications on admission the preadmission medication list is accurate and complete verified per outside documents patient not sure what he is on at home brimonidine tartrate ophth drop left eye q8h losartan potassium mg po daily magnesium oxide mg po bid divalproex extended release mg po bid divalproex extended release mg po qhs gabapentin mg po tid ibrutinib mg oral daily ziprasidone hydrochloride mg po bid metoprolol tartrate mg po bid metformin glucophage mg po bid dextrose maltodextrin gram gram oral daily prn senna mg po bid prn constipation fenofibrate mg po daily atorvastatin mg po qpm glargine units breakfast glargine units dinner insulin sc sliding scale using hum insulin furosemide mg po daily multivitamins tab po daily hydrocodone acetaminophen 5mg 325mg tab po bid ibuprofen mg po q8h prn pain moderate pantoprazole mg po q24h aspirin mg po daily vitamin d unit po every month albuterol sulfate mg ml inhalation qid prn fluoxetine mg po daily trazodone mg po qhs capsaicin appl tp qid shoulder pain levothyroxine sodium mcg po daily cyanocobalamin mcg po daily rivaroxaban mg po daily sodium chloride nasal spry nu qid prn congestion discharge medications clopidogrel mg po daily for months following drug eluding stent rx clopidogrel mg tablet s by mouth once a day disp tablet refills glargine units breakfast glargine units dinner insulin sc sliding scale using hum insulin albuterol sulfate mg ml inhalation qid prn aspirin mg po daily atorvastatin mg po qpm brimonidine tartrate ophth drop left eye q8h capsaicin appl tp qid shoulder pain cyanocobalamin mcg po daily dextrose maltodextrin gram gram oral daily prn divalproex extended release mg po bid divalproex extended release mg po qhs fenofibrate mg po daily fluoxetine mg po daily furosemide mg po daily gabapentin mg po tid hydrocodone acetaminophen 5mg 325mg tab po bid levothyroxine sodium mcg po daily losartan potassium mg po daily magnesium oxide mg po bid metoprolol tartrate mg po bid multivitamins tab po daily pantoprazole mg po q24h rivaroxaban mg po daily senna mg po bid prn constipation sodium chloride nasal spry nu qid prn congestion trazodone mg po qhs vitamin d unit po every month ziprasidone hydrochloride mg po bid held ibrutinib mg oral daily this medication was held do not restart ibrutinib until held metformin glucophage mg po bid this medication was held do not restart metformin glucophage until discharge disposition home with service facility discharge diagnosis nstemi coronary artery disease diabetes hypertension hyperlidpidemia discharge condition hpi this is a year old male with a history of dementa cva hyperlipidemia hypertension and osa transferred for cardiac catheterization following presentation to for chest pain and a mildly elevated troponin he underwent repeat catheterization and received a des to the lad post procedure he is doing well and is looking forward to being discharged his access sites were dry and intact with no erythema excess warmth bleeding or bruit noted vs hr rr sat ra tele sinus rhythem beats svt overnight asymptomatic labs wnl ecg sb bpm labs hct plts inr bun creat na k trop ck mb mag pe general lying on stretcher anxious but cooperative neuro awake alert and oriented x3 vague but appropriate mae ambulating with cane in halls speech clear appropriate and comprehensible heent mm dry neck no lad no jvd cv rrr no m r g chest ls clear bilat abd soft nt ext no edema dp and pulses dopplerable access site without bleeding hematoma or bruit a p m with hx of dementia cvahld htn and osa admitted for chest pain with mildly elevated trop cad s p coronary angiogram no pci initial cath then returned to lab on and a des was placed to lad cont atorvastatin mg and asa mg plavix 75mg daily continue metoprolol losarten htn clinically stable continue losarten metoprolol isosorbide hld cont atorvastatin mg sss s p pacer tele stable history of afib on xarelto now needs triple therapy reviewed with team best plan given cll and risk for bleeding and best evidence fellow recommending to continue xarelto with asa and plavix and for his cardiologist to determine whether to convert to coumadin longer term cll currently on ibutinib po daily per omr notes pt has missed some doses lately this medicine can lead to bleeding thrombycytopenia and neutropenia appears to be tol well so far wbc was when initiated of note no interaction with clopidogrel restart three days post procedure cognitive impairment unclear how severe this is as he remembers most of his meds and seems oriented at present has homemaker and social services extensive medication list concerning depending on supports daily supports at home will have services and home depression on high dose trazadone continue medication regimen right hip pain bursitis on multiple non narcotic pain medicines treatments and getting weekly scripts for vicodin from pcp unable to perform history of medicines vicodin bid only con gabapentin and depakote for hip pain no ibuprofen given risk for bleeding dispo home with daily services as confirmed by cm discharge instructions you were transferred from following presentation there with chest pain and heart attack you underwent an initial cardiac catheterization on and had a stent placement on you were started on a new medication called plavix which is taken to help prevent rethrombosis or clotting off of your stent given that you are currently on xarelto and there is a high risk of bleeding with xarelto aspirin and plavix you will continue plavix for minimum if three months and then consider stopping per instructions from your cardiologist you will continue aspirin mg daily lifelong you should not stop either of these medications unless instructed to do so by your cardiologist you will resume your xarelto tonight per your home regimen you should follow up with your cardiologist in weeks at that time you will be referred for cardiac rehab a referral was provided until that time avoid strenuous exercise it is okay for you to walk specific instructions concerning your access sites are provided separately along with weight bearing restrictions continue to follow a heart healthy carbohydrate consistent diet your metformin was held and may be resumed on additionally you should follow up with your pcp weeks you may resume your ibrutinib on it was held for three days post procedure per the recommendation of the oncologist due to the bleeding risk concern during your procedure you were seen by physical therapy prior to discharge and recommended independent walking inside of house and cane use for outside activity you will continue after discharge in the home setting a cardiac rehab referral was given and will be discussed at follow up appointment with cardiology followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies penicillins codeine acetaminophen oxycodone attending chief complaint chest pain major surgical or invasive procedure none history of present illness yo m with cll on ibrutinib htn t2dm sss s p ppm a paced lrl appears hx of af on xarelto cad s p lhc with des x2 placed in mid lad now presenting with constant chest pain on left radiating down arm chest pain is described as a central substernal chest pressure like a fist into the chest patient did not have nitroglycerin at home chest pain was precipitated by him walking his dog at around on pain was accompanied by shortness of breath reports he feels worse than the chest pain that brought him in with the lad occlusion received asa 325mg via ems given nitro by ems as well with some improvement in his chest pain ems stated he had one episode beat run of nsvt in ambulance in the ed initial vitals t hr bp ra later vitals in the ed notable for bradycardia with intermittent a pacing dependency between exam notable for rrr no murmurs clear lungs trace edema labs notable for trop x2 na wbc hgb imaging notable for unremarkable cxr patient given asa by ems iv hydromorphone dilaudid mg iv hydromorphone dilaudid mg po ng gabapentin mg po ng trazodone mg iv heparin started iv drip nitroglycerin mcg kg min ordered started mcg kg min iv drip nitroglycerin stopped unscheduled iv heparin confirmed no change in rate rate continued at units hr po divalproex extended release mg iv heparin stopped 5h iv hydromorphone dilaudid mg vitals prior to transfer ra on arrival to the floor pt reports chest pain from with dilaudid adm in ed minutes ago denies associated sx n v headache shortness of breath palpitations reports feeling well after stent no pain or shortness of breath until pain has persisted since onset with only slight relief from nitro or dilaudid past medical history cll ppm for bradycardia stroke in htn hld dm social history family history no cancer or stroke physical exam vitals 96ra bp re check general alert oriented no acute distress heent sclera anicteric mmm oropharynx clear neck supple jvp not elevated lungs clear to auscultation bilaterally no wheezes rales rhonchi cv bradycardic regular normal s1 s2 ii vi systolic murmur best heard abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused no cyanosis edema to mid shins skin without rashes or lesions neuro a ox3 grossly intact pertinent results 05pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 05pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 05pm blood hypochr normal anisocy poiklo macrocy normal microcy polychr normal ovalocy tear 05pm blood ptt 05pm blood glucose urean creat na k cl hco3 angap 05pm blood alt ast alkphos totbili 05pm blood lipase 32am blood ctropnt 05pm blood ctropnt 32am blood ck mb 05pm blood albumin calcium phos mg 05pm blood osmolal brief hospital course with cll htn hld t2dm cad s p stenting to lad on presenting with chest pain concerning for unstable angina chest pain hx cad clinical history is concerning for acs s p 2x des to the lad on for a stenosis patient was reportedly out walking when the pain started and he clearly describes chest pressure like a fist into his chest partially responsive to nitro gtt and dilaudid but also reproducible on exam heparin gtt started initially but cardiology consultant recommended discontinuation recent cath with single vessel disease now s p pci no biomarker elevation or ekg change to raise concern for stent thrombosis patient has no untreated disease to cause ischemic symptoms no indication to re cath reproducible pain points toward non cardiac etiology discussion with outpatient provider indicates pain contract and possible history of drug seeking behavior he was given home medications re assured about the non cardiac nature of his chest pain and discharged home sss s p pacemaker a paced in this admission normotensive at this rate off nitro gtt h o afib continued home xeralto hypertension continued home metoprolol and losartan cll patient should continue ibrutinib at home t2dm home insulin continued and metformin held while inpatient no changes to home regimen on discharge depression cognitive impairment continued home ziprasidone fluoxetine and divalproex chronic issues hyperlipidemia continue atorvastatin 80mg qhs depression continue high dose trazodone which is his home medication hypothyroidism continue home levothyroxine r hip pain due to bursitis has required vicodin bid as well as gabapentin and depakote core measures code status presumed full contact medications on admission the preadmission medication list may be inaccurate and requires futher investigation aspirin mg po daily atorvastatin mg po qpm brimonidine tartrate ophth drop left eye q8h cyanocobalamin mcg po daily divalproex extended release mg po bid divalproex extended release mg po qhs fluoxetine mg po daily furosemide mg po daily gabapentin mg po tid hydrocodone acetaminophen 5mg 325mg tab po bid levothyroxine sodium mcg po daily losartan potassium mg po daily magnesium oxide mg po bid metoprolol tartrate mg po bid pantoprazole mg po q24h senna mg po bid prn constipation trazodone mg po qhs metformin glucophage mg po bid fenofibrate mg po daily dextrose maltodextrin gram gram oral daily prn capsaicin appl tp qid shoulder pain albuterol sulfate mg ml inhalation qid prn multivitamins tab po daily vitamin d unit po every month ziprasidone hydrochloride mg po bid ibrutinib mg oral daily sodium chloride nasal spry nu qid prn congestion clopidogrel mg po daily rivaroxaban mg po daily glargine units breakfast glargine units bedtime insulin sc sliding scale using hum insulin discharge medications albuterol sulfate mg ml inhalation qid prn aspirin mg po daily atorvastatin mg po qpm brimonidine tartrate ophth drop left eye q8h capsaicin appl tp qid shoulder pain clopidogrel mg po daily cyanocobalamin mcg po daily dextrose maltodextrin gram gram oral daily prn divalproex extended release mg po bid divalproex extended release mg po qhs fenofibrate mg po daily fluoxetine mg po daily furosemide mg po daily gabapentin mg po tid hydrocodone acetaminophen 5mg 325mg tab po bid ibrutinib mg oral daily glargine units breakfast glargine units bedtime insulin sc sliding scale using hum insulin levothyroxine sodium mcg po daily losartan potassium mg po daily magnesium oxide mg po bid metformin glucophage mg po bid metoprolol tartrate mg po bid multivitamins tab po daily pantoprazole mg po q24h rivaroxaban mg po daily senna mg po bid prn constipation sodium chloride nasal spry nu qid prn congestion trazodone mg po qhs vitamin d unit po every month ziprasidone hydrochloride mg po bid discharge disposition home with service facility discharge diagnosis primary atypical chest pain discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear mr you came to because you were having chest pain we evaluated you very carefully and determined that you were not having a heart attack and that your pain is very likely not coming from your heart your symptoms are probably coming from your ribs and the muscles of your chest we recommend tylenol and your home pain medication for this you can follow up with your usual doctor to see if there is anything else that can be done to help this pain best wishes your care team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies penicillins nsaids non steroidal anti inflammatory drug erythromycin base attending chief complaint chest pain major surgical or invasive procedure none history of present illness year old male with history of cad s p pci to the lad atrial fibrillation s p ppm diabetes hypertension hyperlipidemia and recent diagnosis of testicular cancer presenting with chest pain patient notes sudden onset chest pain at he notes this pain is similar to prior pain at time of mi in described as crushing burning substernal chest pain like a fist into the chest radiating to left arm he took mg asa prior to presentation to he reported to the nurse at that the pain was since but reported to the md at that it was since hours pta to time of presentation pm progressively worsening ekg there reportedly in nsr narrow complex without st elevations chest x ray reportedly unremarkable patient was given of morphine and nitroglycerin sl with some improvement in pain the plan at was to admit for observation with telemetry and trending with cardiac troponins however patient requested transfer to as he had received previous care here of note patient was recently diagnosed with testicular cancer at with recent surgery with urology at his plavix was held for days prior to the surgery and then restarted one day after in addition and notes that patient has had history of drug seeking behavior with frequent requests for benzodiazepines and opiates pain contract in place and note to not administer any narcotics in er due to hx ed visits that are triggered by drug seeking behavior in the ed initial vitals were temp hr bp rr ra ekg sinus rhythm hr labs studies notable for trop wbc hg platelets patient was given iv lorazepam mg iv drip nitroglycerin mcg kg min ordered iv morphine sulfate mg iv morphine sulfate mg hydromorphone dilaudid mg vitals on transfer hr bp rr spo2 ra on the floor patient notes notes ongoing substernal chest pain with radiation to the left arm patient states that since his pci in he has not had any more chest pain until now states patient however per chart review was admitted in for chest pain he was requesting to eat and states that his pain medication of choice is iv dilaudid we explained that if concerned for cardiac cause would not want to mask his chest pain and if there were any potential intervention would want to keep him npo his chest pain improved to patient notes he is very anxious over receiving diagnosis of aggressive testicular cancer on he notes he is scheduled for a pan scan on to evaluate for metastasis he notes severe anxiety over this with support from his son and wife patient notes he would be ok with sw consult for coping past medical history cardiac risk factors diabetes hypertension dyslipidemia cardiac history coronary artery disease s p des to lad in atrial fibrillation s p ppm other past medical history cll stroke in social history family history no cancer or stroke physical exam physical exam on admission discharge vs ra general wdwn male in nad oriented x3 mood affect appropriate heent ncat sclera anicteric perrl eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthelasma neck supple with jvp flat cardiac pmi located in intercostal space midclavicular line rr normal s1 s2 sem lsb no thrills lifts lungs no chest wall deformities scoliosis or kyphosis resp were unlabored no accessory muscle use no crackles wheezes or rhonchi abdomen soft ntnd no hsm or tenderness extremities no c c e no femoral bruits skin no stasis dermatitis ulcers scars or xanthomas pulses distal pulses palpable and symmetric pertinent results lab results on admission 43am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 43am blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 43am blood glucose urean creat na k cl hco3 angap 25am blood calcium phos mg pertinent interval labs 43am blood ctropnt 25am blood ck mb ctropnt cardiac perfusion pharm summary from the exercise lab for pharmacologic stress dipyridamole was infused intravenously for approximately minutes at a dose of milligram kilogram min to minutes after the cessation of infusion the stress dose of the radiotracer was injected findings calculated end diastolic volume is cc however visual observation suggests that the left ventricular cavity size is normal there is a small fixed defect within the inferior wall that is consistent with attenuation and does not appear on the attenuation correction images otherwise rest and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium gated images reveal normal wall motion the calculated left ventricular ejection fraction is impression normal myocardial perfusion study brief hospital course year old male with history of cad s p pci to the lad atrial fibrillation s p ppm diabetes hypertension hyperlipidemia and recent diagnosis of testicular cancer presenting with chest pain with no ischemic st changes negative troponins x and normal myocardial perfusion study likely in setting of anxiety atypical chest pain patient with known cad and recent pci to lad in with recent holding of clopidogrel in setting of orchiectomy although months post stent patient notes abrupt onset of chest pain initially reported as similar in character to prior mi but later reported that he thought this was most likely secondary to anxiety and was much improved with benzodiazepines ekg without ischemic st changes atrially paced troponin i negative at x troponin t negative x here patient was initially placed on nitro gtt and continued on home rivaroxaban given history of known coronary artery disease given history of cad patient underwent p mibi with dipyridamole stress no anginal type symptoms or significant st segment changes nuclear report normal myocardial perfusion study with calculated lvef suspect that chest pain may be secondary to anxiety given recent diagnosis of testicular cancer transitional issues troponins negative x nuclear stress test without evidence of ischemia chest pain most likely related to anxiety please consider social work for coping as an outpatient no changes were made to patient s home medications medications on admission the preadmission medication list is accurate and complete aspirin mg po daily acyclovir mg po q8h docusate sodium mg po bid prn constipation senna mg po daily prn constipation losartan potassium mg po daily trazodone mg po qhs multivitamins tab po daily furosemide mg po daily metoprolol tartrate mg po bid atorvastatin mg po qpm metformin glucophage mg po bid levothyroxine sodium mcg po daily melatonin mg oral qhs prn ibrutinib oral daily gabapentin mg po tid acetaminophen mg po q8h magnesium oxide mg po bid ziprasidone hydrochloride mg po bid fluoxetine mg po daily pantoprazole mg po q24h cyanocobalamin mcg po daily neomycin polymyxin bacitracin appl tp tid rivaroxaban mg po daily clopidogrel mg po daily divalproex extended release mg po bid divalproex extended release mg po qpm hydrocodone acetaminophen 5mg 325mg tab po q8h prn pain moderate milk of magnesia ml po qhs prn constipation glargine units breakfast glargine units dinner discharge medications glargine units breakfast glargine units dinner acetaminophen mg po q8h acyclovir mg po q8h aspirin mg po daily atorvastatin mg po qpm clopidogrel mg po daily cyanocobalamin mcg po daily divalproex extended release mg po bid divalproex extended release mg po qpm docusate sodium mg po bid prn constipation fluoxetine mg po daily furosemide mg po daily gabapentin mg po tid hydrocodone acetaminophen 5mg 325mg tab po q8h prn pain moderate ibrutinib oral daily levothyroxine sodium mcg po daily losartan potassium mg po daily magnesium oxide mg po bid melatonin mg oral qhs prn metformin glucophage mg po bid metoprolol tartrate mg po bid milk of magnesia ml po qhs prn constipation multivitamins tab po daily neomycin polymyxin bacitracin appl tp tid pantoprazole mg po q24h rivaroxaban mg po daily senna mg po daily prn constipation ziprasidone hydrochloride mg po bid discharge disposition home discharge diagnosis primary diagnosis atypical chest pain anxiety discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr it was a pleasure taking care of you at you came to us after sudden onset of chest pain at rest which initially reminded you of your prior heart attack while you were here with us we performed multiple ekgs and sent out blood tests to look for a heart attack good news this did not demonstrate anything that was concerning for a heart attack due to your history of a stent in we ordered a nuclear stress test which did not demonstrate any heart damage as you had been under significant stress recently in the setting of new diagnosis of testicular cancer we would like to encourage you to talk to social work as an outpatient please take care we wish you the best sincerely your care team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies penicillins nsaids non steroidal anti inflammatory drug erythromycin base attending chief complaint fall weakness fatigue major surgical or invasive procedure none history of present illness mr is a year old gentleman with history of cad s p des sss s p ppm paf on rivaroxaban in addition to rai iii cll on ibrutinib and stage iiia nsgct s p radical orchiectomy and now on c2d7 of ep who presents with generalized weakness a fall and abdominal discomfort mr was in his usual state of health until days prior to admission when he began having generalized fatigue and malaise that has progressively worsened since then on the day of admission he was walking back to the bathroom and felt his legs give out falling forward on his knees and hands he denies loss of consciousness dizziness lightheadedness head strike he is having some vague upper gastrointestinal upset over the past days along with some intermittent dyspnea he denies having nausea vomiting diarrhea or constipation he has not had chest discomfort palpitations pleuritic chest pain he has been able to tolerate pos ed initial vitals were ra prior to transfer vitals were ra exam in the ed showed pale gentleman without acute distress breathing comfortably on room air shallow respirations bilaterally without ronchi or wheezing no murmurs power port to r scv without overlying erythema drainage tenderness abd soft no ruq tenderness nontender extremities no swelling no tenderness to palpation bilaterally neuro a ox3 ed work up were significant for cbc wbc hgb plt count neuts chemistry na k cl co2 bun creat ca mg po4 lactate coags inr ptt lfts alt ast alk phos total bili lipase cards ekg non ischemic tnt ua wbc rbc prot glu cxr no acute process patient was given aloh simethicone 30ml viscous lidocaine 10ml ondansetron 4mg iv x1 ns 150ml h on arrival to the floor patient reports concern about his elevated lipase and white blood cell count he thinks his cancer may have extended to his pancreas and that his cll has worsened for being off the ibrutinib he continues to feel tired the nausea he felt in the emergency room has improved with ondansetron he is afraid that his kidneys are failing and he would not like to be on dialysis past medical history past oncologic history lymphocytosis incidentally found during a psychiatric hospitalization ct scan showed a slightly enlarged spleen at cm and no adenopathy he met with dr in at wbc was with lymphocytes hgb and platelets flow cytometry was consistent with cll and b cell gene rearrangement confirmed clonality cll fish panel showed a p53 mutation he was asymptomatic at the time of diagnosis and followed with dr wbc gradually uptrended to in in in and on hgb has decreased slightly to and hct with platelets on the labs hematology care transitioned to dr after dr he also started having nightly sweats ct chest without lymphadenopathy or other notable findings initial hematology evaluation for second opinion wbc hgb hct plt peripheral blood flow cytometry and cytogenetics confirmed cll with tp53 deletion ct abdomen pelvis without lymphadenopathy or other notable findings started ibrutinib mg daily ibrutinib held for vitreous bleed ibrutinib restarted per osh records underwent scrotal u s showing heterogeneous left testicle prominent rete testis on right presented to his outpatient hematologist dr a painful swollen left testicle swelling over months worsening pain this had been evaluated on with an ultrasound that did not demonstrate torsion but did show heterogeneous morphology of the left testicle hcg was positive referred to dr ibrutinib held for surgery underwent left radical orchiectomy pathology revealed cm malignant mixed germ cell tumor of the testis embryonal carcinoma teratoma yolk sac tumor choriocarcinoma invading hilar statin vaginalis with lymphatic vascular invasion and metastatic tumor nodules in the spermatic cord pt2nxs1 although no post orch levels beta hcg on up from on afp ldh normal ct torso showing new mm nodule in the left lower lobe and comparison with ct left para aortic lymphadenopathy up to cm and a cm fluid collection in the left inguinal region scrotum felt to be likely postsurgical c1d1 ep c2d1 ep past medical history sick sinus syndrome s p ppm revo ddd mri compatible cad s p des to mid lad in preserved lvef in stroke diabetes mellitus type ii on insulin hypertension hyperlipidemia morbid obesitys p gastric bypass surgery obstructive sleep apnea not on cpap pancreatitis related to alcohol s p cholecystectomy hypothyroidism osteoarthritis s p bilateral shoulder surgery chronic pain major depression with psychotic features vs schizoaffective disorder per patient dr name unknown affiliated with anxiety conversion disorder benign paroxysmal positional vertigo glaucoma cataract dr at social history family history no cancer or stroke physical exam admission physical exam vs po ra general chronically ill appearing gentleman in emotional distress lying in bed heent anicteric perll mucous membranes dry op clear cardiac regular rate and rhythm normal heart sounds no murmurs rubs or gallops jvp 1cm above clavicle lung appears in no respiratory distress clear to auscultation bilaterally no crackles wheezes or rhonchi abd non distended bowel sounds increased in frequency and volume but normal tone soft non tender no guarding no palpable masses no organomegaly ext warm well perfused no lower extremity edema no erythema or tenderness neuro a ox3 good attention and linear thought cn ii xii intact strength full throughout sensation to light touch intact psych anxious mood and affect skin no significant rashes discharge physical exam vitals ra general chronically ill appearing gentleman sitting up in chair eating breakfast heent anicteric sclera perll mmm op clear cardiac regular rate and rhythm normal heart sounds no murmurs rubs or gallops lung appears in no respiratory distress clear to auscultation bilaterally no crackles wheezes or rhonchi abd non distended soft non tender no guarding no palpable masses no organomegaly ext warm well perfused trace to lower extremity edema bilaterally no erythema or tenderness neuro a ox3 good attention and linear thought cn ii xii intact strength full throughout sensation to light touch intact psych calm and cooperative skin no significant rashes pertinent results admission labs 00pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00pm blood neuts bands monos eos baso myelos nrbc absneut abslymp absmono abseos absbaso 00pm blood hypochr normal anisocy poiklo macrocy normal microcy normal polychr normal ovalocy tear dr acantho 00pm blood ptt 00pm blood glucose urean creat na k cl hco3 angap 00pm blood alt ast alkphos totbili 00pm blood lipase 00pm blood albumin calcium phos mg 11am blood tsh 00pm blood lactate microbiology pm rapid respiratory viral screen culture source nasopharyngeal swab respiratory viral culture pending respiratory viral antigen screen final negative for respiratory viral antigen specimen screened for adeno parainfluenza influenza a b and rsv by immunofluorescence refer to respiratory viral culture and or influenza pcr results listed under other tab for further information imaging studies cxr impression no acute cardiopulmonary process discharge labs 30am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30am blood glucose urean creat na k cl hco3 angap 30am blood calcium phos mg brief hospital course mr is a year old gentleman with history of cad s p des sss s p ppm paf on rivaroxaban in addition to rai iii cll on ibrutinib currently on hold and stage iiia nsgct s p radical orchiectomy and now s p initiation of cycle of cisplatin etoposide who presents with generalized weakness poor po intake a fall and abdominal discomfort weakness hypovolemia acute kidney injury weakness and fatigue are similar to what he experienced for a week during his first cycle of chemotherapy volume depleted on admission due to poor po intake and ongoing use of furosemide cr elevated to on admission was given l ivf with improvement in cr to flu swab negative respiratory viral panel negative for adeno parainfluenza influenza a b and rsv viral culture pending at the time of discharge held furosemide and losartan during this admission but will resume on discharge s p fall suspect that fall was due to orthostatic factors owing to volume depletion low suspicion for arrhythmia no suspicion for acs or seizure no secondary injuries on exam patient was ambulatory in the hospital and did not need evaluation epigastric discomfort nausea hyperlipasemia patient had significant upper gi upset and nausea after previous cycle of chemotherapy so likely attributable to chemotherapy mildly elevated lipase very unlikely to represent pancreatitis given absence of significant abdominal pain or tenderness contributing factors for hyperlipasemia in this patient are furosemide renal failure valproate narcotics rygb continued ondansetron and added prochlorperazine and ativan continued home pantoprazole and added sucralfate lipase trended down pt s diet was advanced without issue stage iiia non seminoma testicular cancer leukocytosis with neutrophilia with low risk features has completed c2 c2d1 of cisplatin etoposide received pegfilgrastim on which explains his leukocytosis with neutrophilia did not receive any chemotherapy while in house rai stage iii chronic lymphocytic leukemia lymphocytosis to on differential up from on likely reactive and not reflecting recurrence or acceleration of cll did not receive ibrutinib while inpatient as this is being held while he is on chemo for his testicular cancer coronary artery disease chronic diastolic heart failure history of cva no symptoms suggestive of acute ischemia during this admission ekg non ischemic and initial tnt no acute neurologic symptoms unclear why on atypical dose of 243mg of asa but no evidence supporting this especially while anticoagulated and on clopidogrel with a history of vitreal bleed so treated with asa continued home plavix atorva metoprolol held home furosemide while inpatient paroxysmal atrial fibrillation sick sinus syndrome currently in sinus rhythm warrants continuation of anticoagulation given chadsvasc nnt continued dose reduced rivaroxaban 10mg with dinner ppm active in ddd mode type diabetes mellitus c b nephropathy last a1c held metformin in setting of continued home glargine 56sc bid humalog sliding scale depressive disorder with psychotic features anxiety appropriately anxious affect while hospitalized no positive or negative psychotic symptoms continued home psychiatric medications chronic back and shoulder pain not exacerbated continued acetaminophen hydrocodone tid prn transitional issues respiratory viral culture pending at the time of discharge he has been on triple anticoagulation with aspirin clopidogrel and rivaroxaban ibrutinib adds additional bleeding risk though he is not currently on this patient will follow up with his cardiologist for discussion of continuing clopidogrel for lad stent placed in nausea added compazine during this admission benefit from addition of ativan or olanzapine to his anti emetic regimen for the next round of chemotherapy code full code presumed not addressed in setting of marked anxiety no urgency given clinical stability emergency contact hcp son phone number on admission the preadmission medication list is accurate and complete acetaminophen mg po q8h prn headache aspirin mg po daily atorvastatin mg po qpm clopidogrel mg po daily metoprolol tartrate mg po bid divalproex extended release mg po bid divalproex extended release mg po qpm docusate sodium mg po bid constipation fluoxetine mg po daily furosemide mg po daily gabapentin mg po tid hydrocodone acetaminophen 5mg 325mg tab po q8h prn pain moderate levothyroxine sodium mcg po daily losartan potassium mg po daily magnesium oxide mg po bid melatonin mg oral qhs prn metformin glucophage mg po bid pantoprazole mg po q24h rivaroxaban mg po daily senna mg po daily constipation glargine units breakfast glargine units bedtime trazodone mg po qhs discharge medications prochlorperazine mg po q6h prn nausea rx prochlorperazine maleate mg tablet s by mouth q6h prn disp tablet refills sucralfate gm po tid prn upset stomach with meals rx sucralfate gram ml ml by mouth tid prn refills acetaminophen mg po q8h prn headache aspirin mg po daily atorvastatin mg po qpm clopidogrel mg po daily divalproex extended release mg po bid divalproex extended release mg po qpm docusate sodium mg po bid constipation fluoxetine mg po daily furosemide mg po daily gabapentin mg po tid hydrocodone acetaminophen 5mg 325mg tab po q8h prn pain moderate glargine units breakfast glargine units bedtime levothyroxine sodium mcg po daily losartan potassium mg po daily magnesium oxide mg po bid melatonin mg oral qhs prn metformin glucophage mg po bid metoprolol tartrate mg po bid pantoprazole mg po q24h rivaroxaban mg po daily senna mg po daily constipation trazodone mg po qhs discharge disposition home with service facility discharge diagnosis primary diagnoses volume depletion acute kidney injury testicular cancer secondary diagnoses chronic lymphocytic leukemia coronary artery disease diabetes mellitus type 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 did you come to the hospital you were feeling weak and tired and you had a fall at home this was likely due to dehydration what happened while you were here we treated you with iv fluids and started some new medicines for nausea what should you do when you leave the hospital please continue to take all of your medications as directed and follow up with all of your doctors again it was a pleasure taking care of you sincerely your team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies penicillins nsaids non steroidal anti inflammatory drug erythromycin base attending chief complaint fever major surgical or invasive procedure n a history of present illness yo male with a history of cll and more recently testicular cancer who is admitted with fevers cough and sore throat the patient states his symptoms started about two days ago but the fever just started today and has been as high as he denies any associated shortness of breath he has had some intermittent nausea he denies any diarrhea dysuria or rashes of note he has had some mild dyspnea on exertion and palpitations that was thought by his outpatient team to be possibly symptomatic anemia and he was going to have an outpatient red blood cell transfusion but it had not been done yet in the ed a chest x ray and urinalysis were unremarkable his labwork was notable for wbc hgb and platelets a rapid flu test was negative he was given cefepime of note he was recently hospitalized from with weakness and falls which was thought to be due to poor po intake after his recent chemotherapy review of systems all reviewed and negative except as noted in the hpi past medical history past oncologic history per omr cll 17p and stage iiia mixed germ cell tumor of the testis lymphocytosis incidentally found during a psychiatric hospitalization ct scan showed a slightly enlarged spleen at cm and no adenopathy he met with dr in at was with lymphocytes hgb and platelets flow cytometry was consistent with cll and b cell gene rearrangement confirmed clonality cll fish panel showed a p53 mutation he was asymptomatic at the time of diagnosis and followed with dr wbc gradually uptrended to in in in and on hgb has decreased slightly to and hct with platelets on the labs hematology care transitioned to dr after dr he also started having nightly sweats ct chest without lymphadenopathy or other notable findings initial hematology evaluation for second opinion wbc hgb hct plt peripheral blood flow cytometry and cytogenetics confirmed cll with tp53 deletion ct abdomen pelvis without lymphadenopathy or other notable findings started ibrutinib mg daily ibrutinib held for vitreous bleed ibrutinib restarted per osh records underwent scrotal u s showing heterogeneous left testicle prominent rete testis on right presented to his outpatient hematologist dr a painful swollen left testicle swelling over months worsening pain this had been evaluated on with an ultrasound that did not demonstrate torsion but did show heterogeneous morphology of the left testicle hcg was positive referred to dr ibrutinib held for surgery underwent left radical orchiectomy pathology revealed cm malignant mixed germ cell tumor of the testis embryonal carcinoma teratoma yolk sac tumor choriocarcinoma invading hilar statin vaginalis with lymphatic vascular invasion and metastatic tumor nodules in the spermatic cord pt2nxs1 although no post orch levels beta hcg on up from on afp ldh normal ct torso showing new mm nodule in the left lower lobe and comparison with ct left para aortic lymphadenopathy up to cm and a cm fluid collection in the left inguinal region scrotum felt to be likely postsurgical c1d1 ep c2d1 ep past medical history sick sinus syndrome s p ppm revo ddd mri compatible cad s p des to mid lad in preserved lvef in stroke diabetes mellitus type ii on insulin hypertension hyperlipidemia morbid obesitys p gastric bypass surgery obstructive sleep apnea not on cpap pancreatitis related to alcohol s p cholecystectomy hypothyroidism osteoarthritis s p bilateral shoulder surgery chronic pain major depression with psychotic features vs schizoaffective disorder per patient dr name unknown affiliated with anxiety conversion disorder benign paroxysmal positional vertigo glaucoma cataract dr at social history family history no known history of malignancies physical exam admission physical exam general nad vital signs t bp hr rr o2 ra heent mmm no op lesions cv rr nl s1s2 pulm ctab abd soft ntnd no masses or hepatosplenomegaly limbs trace bilateral lower extremity edema skin no rashes or skin breakdown neuro alert and oriented no focal deficits discharge physical exam general pleasant man sitting up in chair in nad vital signs t bp hr rr o2 ra heent mmm no op lesions erythema or purulence no lad cv rr nl s1s2 sem pulm nonlabored appearing ctab no cough this morning abd obese soft ntnd no masses or hepatosplenomegaly limbs bilateral lower extremity edema l r skin no rashes or skin breakdown neuro alert and oriented no focal deficits pertinent results admission labs 20pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 20pm blood neuts bands monos eos baso metas myelos nrbc absneut abslymp absmono abseos absbaso 20pm blood ptt 20pm blood glucose urean creat na k cl hco3 angap 48am blood alt ast alkphos totbili 48am blood calcium phos mg 48am blood igg iga igm discharge labs 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood neuts bands lymphs monos eos baso metas myelos absneut abslymp absmono abseos absbaso 00am blood glucose urean creat na k cl hco3 angap 00am blood albumin calcium phos mg trop trend 19am blood ck mb ctropnt 00pm blood ck mb ctropnt na 00am blood glucose urean creat na k cl hco3 angap 00am blood osmolal 11am urine hours random na 11am urine osmolal 00am blood na imaging imaging unilat lower ext veins no evidence of deep venous thrombosis in the visualized right lower extremity veins right peroneal veins not visualized imaging cta chest new opacities in the right lower lobe are concerning for infection versus aspiration no evidence of pulmonary embolism or aortic abnormality there has been interval resolution of the previously seen mm nodule in the left lower lobe from imaging chest pa lat persistent low lung volumes without focal consolidation stable mild cardiomegaly without overt pulmonary edema micro urine legionella urinary antigen final inpatient rapid respiratory viral screen culture respiratory viral culture final parainfluenza virus type respiratory viral antigen screen final inpatient urine urine culture final emergency ward blood culture blood culture routine pending emergency ward blood culture blood culture routine pending brief hospital course principle reason for admission yo male with a history of cll and more recently testicular cancer who is admitted with fevers cough and sore throat course notable for nausea vomiting and intermittent palpitations fever parainfluenza bronchitis pharyngitis patient febrile to arrival but no fever noted in the hospital blood and urine cultures remain negative most prominent symptoms were sore throat dry cough and nausea vomiting he was treated symptomatically and slowly improved during his course nasopharyngeal swab obtained on admission eventually grew parainfluenza type of note cta showed mild area of possible infection in rll and he was empirically started on clindamycin for aspiration pna has pcn allergy however this was discontinued after one day given concern it was worsening his nausea additionally noted to have low igg igm we discussed with his outpatient oncology team and decided against ivig nausea vomiting patient developed marked nauasea and vomiting on hospital days and abdomen was benign on exam and lft chemistry panel generally unremarkable he did have elevated white count but no diarreha to suggest cdiff somewhat unclear etiology but ultimately felt related to parainfluenzae greatly improved after reducing dietary allowance and slowly advanced back to full diet he was treated supportively treatment with iv zofran compazine ativan and olanzapine as needed palpitations dyspnea on exertion patient reported several weeks of doe and palpitations with exertion he continued to have these during his stay although no vs derangements were noted during episodes had been thought that symptomatic anemia was playing a role but no significant improvement with units prbc he was monitored on telemetry and acs ruled out with serial troponins cta was negative for pe cardiology was consulted interrogate ppm and no significant arrhythmias were noted left lower extremity swelling likely worsened in setting of holding home lasix and providing ivf for nausea vomiting was negative for dvt hyponatremia na was noted to be on day of discharge felt likely due to nausea and vomiting and decreased po intake day prior urine was appropriately dilute and was given 500cc additional fluid na improved to prior to discharge anemia chemotherapy induced no signs of active bleeding sp units prbc leukocytosis most likely due to recent neulasta and less likely from cll given profound left shift no clear bacterial infection as above and antibiotics were held aside from one day of clindamycin testicular cancer received c2d1 etoposide and cisplatin on received neulasta on next cycle planned for ultimately deferred to next week cll treatment on hold while the patient is being treated for testicular cancer continued home acyclovir dm continued home lantus held home metformin while in house and maintained hiss cad continued home aspirin atorvastatin clonidine plavix lasix and losartan depression anxiety continued home trazadone ziprasidone fluoxetine and divalproex hypothyroidism continued home levothyroxine atrial fibrillation continue home metoprolol and rivaroxaban fen electrolytes per oncology scales regular diet pain continue home gabapentin oxycodone prn avoid tylenol acutely to avoid masking fevers bowel regimen continue home colace and senna dvt prophylaxis continue home rivaroxaban access port billing minutes spend planning and executing this discharge plan transitional issues please follow up in clinic on to consider next cycle chemo please recheck na to monitor hyponatremia medications on admission the preadmission medication list is accurate and complete acetaminophen mg po q8h prn headache atorvastatin mg po qpm clopidogrel mg po daily divalproex extended release mg po bid divalproex extended release mg po qpm docusate sodium mg po bid constipation fluoxetine mg po daily gabapentin mg po tid hydrocodone acetaminophen 5mg 325mg tab po q8h prn pain moderate levothyroxine sodium mcg po daily magnesium oxide mg po bid metoprolol tartrate mg po bid pantoprazole mg po q24h rivaroxaban mg po daily senna mg po daily constipation trazodone mg po qhs prochlorperazine mg po q6h prn nausea sucralfate gm po tid prn upset stomach with meals furosemide mg po daily losartan potassium mg po daily melatonin mg oral qhs prn metformin glucophage mg po bid aspirin mg po daily glargine units breakfast glargine units bedtime acyclovir mg po q8h clonidine mg po tid fenofibrate mg po daily ziprasidone hydrochloride mg po bid discharge medications cepacol sore throat lozenge loz po q2h prn sore throat rx benzocaine menthol cepacol sore throat mg mg lozenge q4 hours disp lozenge refills guaifenesin dextromethorphan ml po q6h prn cough rx dextromethorphan guaifenesin mg mg ml ml by mouth q4 hours refills acetaminophen mg po q8h prn headache acyclovir mg po q8h aspirin mg po daily atorvastatin mg po qpm clonidine mg po tid clopidogrel mg po daily divalproex extended release mg po bid divalproex extended release mg po qpm docusate sodium mg po bid constipation fenofibrate mg po daily fluoxetine mg po daily furosemide mg po daily gabapentin mg po tid hydrocodone acetaminophen 5mg 325mg tab po q8h prn pain moderate glargine units breakfast glargine units bedtime levothyroxine sodium mcg po daily losartan potassium mg po daily magnesium oxide mg po bid melatonin mg oral qhs prn metformin glucophage mg po bid metoprolol tartrate mg po bid pantoprazole mg po q24h prochlorperazine mg po q6h prn nausea rivaroxaban mg po daily senna mg po daily constipation sucralfate gm po tid prn upset stomach with meals trazodone mg po qhs ziprasidone hydrochloride mg po bid discharge disposition home with service facility discharge diagnosis parainfluenzae virus nausea vomiting palpitations discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear were admitted for fevers were found to have a viral infection called parainfluenza virus your symptoms including fever cough sore throat nausea and vomiting improved with time also had a blood transfusion to help improve your breathing and energy tolerated it well we had our cardiologists evaluate your pacemaker given your palpitations and we found no evidence of concerning heart rhythms will need to follow up with your oncology team as scheduled regards your team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies penicillins nsaids non steroidal anti inflammatory drug erythromycin base cheeses attending chief complaint rectal bleeding noted on night prior to admission major surgical or invasive procedure colonoscopy aborted due to poor bowel prep history of present illness mr is a male with history of cll on ibrutinib non seminoma testicular gct t2n2m1a stage iiia s p ep x4 completed with normalization of markers and residual lad cm now on surveillance cad s p lad pci in sss s p ppm paroxysmal atrial fibrillation on rivaroxaban cva dmii depression who presents for brbpr patient reports brbpr since 5pm on wednessday he first noticed the bleeding when he took off his bathrobe to take a shower he wiped the area with a towel and noted to have dark red blood he reports having a colonoscopy about years ago he notes continued rectal bleeding he also noticed increasing bruising over his forearms he denies any other symptoms on arrival to the ed initial vitals were ra exam notable for red blood on rectal labs were notable for wbc h h at baseline plt inr na k bun cr lactate and ua negative urine culture was sent no imaging obtained no medications given gi was consulted and recommended admission and prep for colonoscopy prior to transfer vitals were ra on arrival to the floor patient reports feeling like his blood sugar is low he also notes pain on his tailbone due to a fall years ago and lying in bed all day he denies fevers chills night sweats headache vision changes dizziness lightheadedness shortness of breath cough hemoptysis chest pain palpitations abdominal pain nausea vomiting diarrhea hematemesis dysuria and hematuria review of systems a complete point review of systems was performed and was negative unless otherwise noted in the hpi past medical history past oncologic history per omr cll 17p and stage iiia mixed germ cell tumor of the testis lymphocytosis incidentally found during a psychiatric hospitalization ct scan showed a slightly enlarged spleen at cm and no adenopathy he met with dr in at wbc was with lymphocytes hgb and platelets flow cytometry was consistent with cll and b cell gene rearrangement confirmed clonality cll fish panel showed a p53 mutation he was asymptomatic at the time of diagnosis and followed with dr wbc gradually uptrended to in in in and on hgb has decreased slightly to and hct with platelets on the labs hematology care transitioned to dr after dr he also started having nightly sweats ct chest without lymphadenopathy or other notable findings initial hematology evaluation for second opinion wbc hgb hct plt peripheral blood flow cytometry and cytogenetics confirmed cll with tp53 deletion ct abdomen pelvis without lymphadenopathy or other notable findings started ibrutinib mg daily ibrutinib held for vitreous bleed ibrutinib restarted per osh records underwent scrotal u s showing heterogeneous left testicle prominent rete testis on right presented to his outpatient hematologist dr a painful swollen left testicle swelling over months worsening pain this had been evaluated on with an ultrasound that did not demonstrate torsion but did show heterogeneous morphology of the left testicle hcg was positive referred to dr ibrutinib held for surgery underwent left radical orchiectomy pathology revealed cm malignant mixed germ cell tumor of the testis embryonal carcinoma teratoma yolk sac tumor choriocarcinoma invading hilar statin vaginalis with lymphatic vascular invasion and metastatic tumor nodules in the spermatic cord pt2nxs1 although no post orch levels beta hcg on up from on afp ldh normal ct torso showing new mm nodule in the left lower lobe and comparison with ct left para aortic lymphadenopathy up to cm and a cm fluid collection in the left inguinal region scrotum felt to be likely postsurgical c1d1 ep c2d1 ep past medical history sick sinus syndrome s p ppm revo ddd mri compatible cad s p des to mid lad in preserved lvef in stroke diabetes mellitus type ii on insulin hypertension hyperlipidemia morbid obesitys p gastric bypass surgery obstructive sleep apnea not on cpap pancreatitis related to alcohol s p cholecystectomy hypothyroidism osteoarthritis s p bilateral shoulder surgery chronic pain major depression with psychotic features vs schizoaffective disorder per patient dr name unknown affiliated with anxiety conversion disorder benign paroxysmal positional vertigo glaucoma cataract dr at social history family history no known history of malignancies physical exam admission physical exam vs temp bp hr rr o2 sat ra general pleasant man in no distress lying in bed comfortably heent anicteric perll op clear cardiac rrr normal s1 s2 no m r g lung appears in no respiratory distress clear to auscultation bilaterally no crackles wheezes or rhonchi abd obese soft non tender non distended normal bowel sounds ext warm well perfused bilateral lower extremity edema neuro a ox3 good attention and linear thought cn ii xii intact strength full throughout sensation to light touch intact skin bruising on bilateral upper extremities access right chest wall port without erythema discharge physical exam vitals reviewed in e flowsheets general in no distress eyes anicteric ent moist mucous membranes cv regular normal s1 s2 respiratory lungs clear bilaterally breathing comfortably gi soft non tender musculoskeletal no edema neurologic face symmetric gaze conjugate speech fluent oriented x4 psychiatric pleasant but flattened integumentary pale pertinent results admission labs 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 40pm blood ptt 00am blood urean creat na k cl hco3 angap 00am blood albumin calcium phos mg 00am blood hba1c eag relevant interval labs 13am blood glucose urean creat na k cl hco3 angap 36am blood cortsol 13am blood osmolal studies ct abdomen pelvis w contrast fluid in the colon can be correlated with diarrhea no imaging findings of colitis or bowel obstruction redemonstration of findings of gastrogastric fistula no new lymphadenopathy or definite evidence of metastatic disease colonscopy aborted due to poor preparation colonoscopy polyps in the cecum and descending colon polypectomy diffuse melanosis noted throughout the colon internal hemorrhoids otherwise normal colonoscopy to cecum discharge labs 47am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt brief hospital course mr is a male with history of cll on ibrutinib non seminoma testicular gct t2n2m1a stage iiia s p ep x4 completed with normalization of markers and residual lad cm now on surveillance cad s p lad pci in sss s p ppm paroxysmal atrial fibrillation on rivaroxaban cva dmii depression who presented with brbpr acute issues gi bleed acute on chronic normocytic anemia with acute blood loss hgb remained stable during hospitlization without any transfusion requirement vitals remained stable as well no significant bleeding observed while hospitalized patient required extremely prolonged colonoscopy preparation days with moviprep magnesium citrate with colonoscopies with inadequate preparation colonsocopy ultimately revealed two benign appearing polyps which were biopsied as well as internal hemorrhoids clopidogrel stopped after discussion with cardiologist as months after pci stenting ibrutinib rivaroxaban held per discussion with oncologist dr restarted at discharge aspirin dose decreased to mg daily hyponatremia developed during bowel preparation improved with iv ns chronic issues cll wbc remained mostly stable ibrutinib held as above and restarted at discharge continued home acyclovir testicular cancer he is s p treatment with etoposide cisplatin with plan for surveillance follow up with dr as scheduled dmii complicated by hypoglycemia unclear etiology long acting insulin was transiently held during limited po intake with bowel prep and adjusted during hospitalization discharged on lantus units bid but will require close monitoring and likely uptitration as an outpatient cad s p pci chronic diastolic heart failure per d w pt s cardiologist dr on ok to decrease home asa from to 81mg daily and to discontinue clopidogrel altogether as it has been months since last pci continued home atorvastatin and fenofibrate held home lasix and losartan in setting of gi bleed home dose metoprolol initially held but restarted paroxysmal atrial fibrillation history of cva sss s p ppm held home rivaroxaban in setting of gi bleed resumed home dose metoprolol resumed rivaroxaban at discharge depression anxiety continued home trazodone ziprasidone fluoxetine clonidine and divalproex added prn low dose lorazepam for increased anxiety while hospitalized discontinued at discharge hypothyroidism continued home levothyroxine chronic back shoulder pain continue home vicodin gabapentin and lidocaine pt received prn one time doses of iv morphine for breakthrough pain with good effect transitional issues biopsy results from colonoscopy pending at discharge clopidogrel stopped asa decreased to 81mg daily persistently hypoglycemic requiring d10w drip though this was in the setting of npo and colonoscopy prep lantus decreased to units bid please increase as an outpatient prn minutes spent on discharge coordination and planning medications on admission the preadmission medication list may be inaccurate and requires futher investigation acyclovir mg po q8h aspirin mg po daily atorvastatin mg po qpm clonidine mg po tid clopidogrel mg po daily divalproex extended release mg po qam divalproex extended release mg po qpm docusate sodium mg po bid constipation fenofibrate mg po daily fluoxetine mg po daily furosemide mg po daily gabapentin mg po tid levothyroxine sodium mcg po daily losartan potassium mg po daily magnesium oxide mg po bid metoprolol tartrate mg po bid pantoprazole mg po q24h prochlorperazine mg po q6h prn nausea vomiting rivaroxaban mg po daily senna mg po bid prn constipation sucralfate gm po tid prn upset stomach with meals trazodone mg po qhs ziprasidone hydrochloride mg po bid acetaminophen mg po q8h prn pain mild hydrocodone acetaminophen 5mg 325mg tab po q8h prn pain moderate melatonin mg oral qhs prn metformin glucophage mg po bid glargine units breakfast glargine units bedtime ibrutinib mg oral daily lidocaine patch ptch td qam discharge medications aspirin mg po daily rx aspirin mg tablet s by mouth daily disp tablet refills glargine units breakfast glargine units bedtime acetaminophen mg po q8h prn pain mild acyclovir mg po q8h atorvastatin mg po qpm clonidine mg po tid divalproex extended release mg po qam divalproex extended release mg po qpm docusate sodium mg po bid constipation fenofibrate mg po daily fluoxetine mg po daily furosemide mg po daily gabapentin mg po tid hydrocodone acetaminophen 5mg 325mg tab po q8h prn pain moderate ibrutinib mg oral daily levothyroxine sodium mcg po daily lidocaine patch ptch td qam losartan potassium mg po daily magnesium oxide mg po bid melatonin mg oral qhs prn metformin glucophage mg po bid metoprolol tartrate mg po bid pantoprazole mg po q24h prochlorperazine mg po q6h prn nausea vomiting rivaroxaban mg po daily senna mg po bid prn constipation sucralfate gm po tid prn upset stomach with meals trazodone mg po qhs ziprasidone hydrochloride mg po bid discharge disposition home with service facility discharge diagnosis gi bleed likely lower acute blood loss anemia type insulin dependent diabetes mellitus complicated by hypoglycemia difficult bowel prep discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr you are admitted to the hospital for evaluation of bleeding from the rectum you are on a number of medications that can increase your risk of bleeding we contacted your cardiologist dr agrees with stopping plavix clopidogrel since it has been more than months since you had a stent placed you required a very prolonged preparation for your colonoscopy which showed polyps they were removed please monitor your blood sugars very closely at home and call your primary doctor if you have any sugars over or lower than your sugars were very low here so we decreased your lantus to units twice a day but once you restart your regular diet you may need to increase your insulin back to units twice a day please note the adjustments to your medications on the medication reconciliation sheet it was a pleasure taking care of you your team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies penicillins nsaids non steroidal anti inflammatory drug erythromycin base cheeses soft cottage cream cheese attending chief complaint chest pain major surgical or invasive procedure none history of present illness with history of cll on ibrutinibm metastatic testicular cancer cad s p lad pci in sss s p ppm paf on rivaroxaban and dm presenting with midsternal chest pain admitted for nuclear stress test he woke up this morning with out of midsternal chest pain radiating to both shoulders he felt like a fist was pushing against my chest and putting pressure down he notes that this pain was re created by pushing on his chest made it difficult for him to breathe in secondary to worsening of his pain and was worse than his prior chest pains he notes no nausea vomiting dizziness lightheadedness abdominal pains or changes in bowel or bladder movements he states that this was at in the morning he thinks he should have called ems at that time however he waited to see if it would pass while he was eating breakfast the pain was so unbearable that he push the lifeline button and had been transferred him to for further evaluation of note in he had an admission for the exact same presentation and history provided at that time he was treated with morphine and nitroglycerin drip with improvement of symptoms no further escalation was done as patient has a history of drug seeking behavior in the past workup at that time was pan negative a stress mibi was performed that demonstrated no signs of acute ischemia or exertional ischemia he has a history of cll with high risk cytogenetics 17p treating with ibrutinib course c b metastatic gct s p ep in he notes that he travelled from in the last several weeks denies leg swelling hemoptysis he was last admitted from to for lgib likely internal hemorrhoids and two benign polyps while on ibrutinib his was discontinued and he was discharged without further issue in the ed he was evaluated with a well score of and a heart score of troponin was negative and pe was ruled out he was given iv morphine low dose aspirin and started on percocet sublingual nitroglycerin reportedly caused worsening of symptoms pharmocologic stress neg in the ed initial vitals were pain on ra ekg normal sinus rhythm normal axis enlarged la lvh by avl criteria pr narrow qrs normal qtc no stemi labs studies notable for wbc hgb plt ct neuts bands lymphs monos eos baso atyps metas myelos absneut abslymp absmono abseos absbaso ptt ctropnt d dimer urean creat cxr no definite acute cardiopulmonary abnormality patient was given mg iv morphine sulfate mg sl nitroglycerin sl mg po oxycodone acetaminophen 5mg 325mg tab vitals on transfer pain ra on the floor he verifies the above history he notes that he is still having out of chest pain radiating to both shoulders he notes that he has difficulty taking deep inspiration secondary to the pain he denies nausea vomiting abdominal pain or increase in lower extreme swelling past medical history past oncologic history per omr cll 17p and stage iiia mixed germ cell tumor of the testis lymphocytosis incidentally found during a psychiatric hospitalization ct scan showed a slightly enlarged spleen at cm and no adenopathy he met with dr in at wbc was with lymphocytes hgb and platelets flow cytometry was consistent with cll and b cell gene rearrangement confirmed clonality cll fish panel showed a p53 mutation he was asymptomatic at the time of diagnosis and followed with dr wbc gradually uptrended to in in in and on hgb has decreased slightly to and hct with platelets on the labs hematology care transitioned to dr after dr he also started having nightly sweats ct chest without lymphadenopathy or other notable findings initial hematology evaluation for second opinion wbc hgb hct plt peripheral blood flow cytometry and cytogenetics confirmed cll with tp53 deletion ct abdomen pelvis without lymphadenopathy or other notable findings started ibrutinib mg daily ibrutinib held for vitreous bleed ibrutinib restarted per osh records underwent scrotal u s showing heterogeneous left testicle prominent rete testis on right presented to his outpatient hematologist dr a painful swollen left testicle swelling over months worsening pain this had been evaluated on with an ultrasound that did not demonstrate torsion but did show heterogeneous morphology of the left testicle hcg was positive referred to dr ibrutinib held for surgery underwent left radical orchiectomy pathology revealed cm malignant mixed germ cell tumor of the testis embryonal carcinoma teratoma yolk sac tumor choriocarcinoma invading hilar statin vaginalis with lymphatic vascular invasion and metastatic tumor nodules in the spermatic cord pt2nxs1 although no post orch levels beta hcg on up from on afp ldh normal ct torso showing new mm nodule in the left lower lobe and comparison with ct left para aortic lymphadenopathy up to cm and a cm fluid collection in the left inguinal region scrotum felt to be likely postsurgical c1d1 ep c2d1 ep past medical history sick sinus syndrome s p ppm revo ddd mri compatible cad s p des to mid lad in preserved lvef in stroke diabetes mellitus type ii on insulin hypertension hyperlipidemia morbid obesitys p gastric bypass surgery obstructive sleep apnea not on cpap pancreatitis related to alcohol s p cholecystectomy hypothyroidism osteoarthritis s p bilateral shoulder surgery chronic pain major depression with psychotic features vs schizoaffective disorder per patient dr name unknown affiliated with anxiety conversion disorder benign paroxysmal positional vertigo glaucoma cataract dr at social history family history no known history of malignancies physical exam admission physical exam vs f on room air general obese man laying in bed wearing home pajamas in no acute distress able to speak in full sentences without gasping for air does not appear to have increased work of breathing heent pupils equal round reactive to light and accommodation extraocular muscles intact non erythematous oropharynx neck supple with jvd to cm cardiac regular rate and rhythm with out of systolic ejection murmur best appreciated at the base lungs poor inspiratory effort however clear to auscultation bilaterally in anterior and posterior fields with no wheezes crackles or rhonchi pain reproduced with palpation at right chest wall at site of costochondral joint abdomen obese soft ntnd no hsm or tenderness port present on right chest wall with bandages clean dry and intact extremities no c c e no femoral bruits skin no stasis dermatitis ulcers scars or xanthomas pulses distal pulses palpable and symmetric discharge physical exam vs po l lying ra general obese man sitting in chair in nad heent pupils equal round reactive to light and accommodation extraocular muscles intact non erythematous oropharynx neck supple with jvp not visible cardiac regular rate and rhythm with out of systolic ejection murmur best appreciated at the base no pericardial rub appreciated no evidence of pulsus paradoxus with mmhg decrease in systolic bp with inspiration lungs poor inspiratory effort however clear to auscultation bilaterally in anterior and posterior fields with no wheezes crackles or rhonchi abdomen obese soft ntnd no hsm or tenderness port present on right chest wall with bandages clean dry and intact extremities trace to edema no femoral bruits skin no stasis dermatitis ulcers scars or xanthomas pulses distal pulses palpable and symmetric pertinent results admission labs 26pm glucose urea n creat sodium potassium chloride total co2 anion gap 26pm ck mb ctropnt 26pm calcium phosphate magnesium 26pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 26pm plt count 48pm urine color yellow appear clear sp 48pm urine blood neg nitrite neg protein tr glucose ketone neg bilirubin neg urobilngn neg ph leuk neg 48pm urine rbc wbc bacteria none yeast none epi 48pm urine hyaline 46am d dimer 55am glucose urea n creat sodium potassium chloride total co2 anion gap 55am estgfr using this 55am ctropnt 55am probnp 55am wbc rbc hgb hct mcv mch mchc rdw rdwsd 55am neuts bands lymphs monos eos basos myelos absneut abslymp absmono abseos absbaso 55am hypochrom normal anisocyt normal poikilocy macrocyt normal microcyt normal polychrom normal elliptocy 55am plt smr normal plt count 55am ptt discharge labs 20am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt portable cxr findings streaky opacity at the right lung base likely represents atelectasis no dense consolidative opacity pleural effusion or pneumothorax identified on single view right sided chest port is seen with tip likely terminating over the right atrium a left sided pacemaker is seen mild cardiomegaly appears similar impression no definite acute cardiopulmonary abnormality tte the left atrium is mildly dilated there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded the aortic root is mildly dilated at the sinus level the aortic valve leaflets are mildly thickened 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 suboptimal image quality trivial pericardial effusion preserved global left ventricular systolic function mildly dilated aortic sinus compared with the prior study images reviewed of the estimated pa systolic pressure is now lower normal cardiac perfusion summary from the exercise lab for pharmacologic stress mg of regadenoson mg ml was infused intravenously over seconds followed by a saline flush findings computer calculated end diastolic volume is borderline at cc however left ventricular cavity size visually appears normal rest and stress perfusion images again reveal a small inferior fixed defect likely secondary to attenuation artifact otherwise there is uniform tracer uptake throughout the left ventricular myocardium gated images reveal normal wall motion the calculated left ventricular ejection fraction is impression normal myocardial perfusion study stress test interpretation this year old man with a history of hypertension diabetes dyslipidemia coronary artery disease s p lad pci referred as an inpatient for the evaluation of chest pain after serial negative cardiac biomarkers he underwent pharmacologic vasodilator perfusion study with 4mg 5ml of regadenason over seconds prior to tracer injection there was no report of any chest back arm jaw or neck discomfort throughout the study there were no significant sttw changes the vasodilator effect was reversed with 125mg of aminophylline iv the rhythm was atrial fibrillation with occasional ventricular paced beats and no ectopy there was an appropriate hemodynamic response to regadenason impression no anginal symptoms or significant sttw changes nuclear report sent separately brief hospital course patient summary male with pmh of cad s p drug eluting stent in sick sinus syndrome status post pacemaker in paroxysmal atrial fibrillation diabetes hypertension and cll who presented with midsternal chest pain and diffuse st segment elevations consistent with pericarditis coronaries mid lad stent pump rhythm paroxysmal atrial fibrillation acute issues chest pain pericarditis patient presented with mid sternal chest pain patient s troponins were negative x4 and d dimer also negative which provided reassurance of non acs and non pe event recreation of patient s chest pain with palpation of his chest wall was initially thought to be most consistent with a costochondritis however ekg obtained upon admission showed diffuse st elevations consistent with pericarditis and the patient was treated empirically for pericarditis tte showed a trivial pericardial effusion and preserved global left ventricular systolic function with a mildly dilated aortic sinus as the patient was unable to receive nsaids due to known cad and questionable gi bleed on last admission he was started on colchicine and prednisone this combination improved his chest pain overall though he continued to have occasional episodes of midsternal pain leading up to discharge these episodes were all self limiting and were not associated with any new ekg changes or troponin elevations the patient underwent a stress test to ensure no ischemic disease he had no anginal symptoms or significant sttw changes during the pharmacological stress and myocardial perfusion was normal the patient will be discharged on colchicine mg bid and a prednisone taper patient s creatinine bumped from on admission to on patient had been npo prior to myocardial perfusion study and the etiology of the was thought to be pre renal this was supported by urine electrolytes studies which revealed a urine na and urine cl also consistent with sodium avid state the patient was treated with a liter fluid bolus and his creatinine rapidly downtrended the patient s creatinine was on discharge dm patient s blood sugars were monitored closely during this admission he initially was very poorly controlled with blood sugars in the mid this was likely due to a delay in restarting his home dose of lantus units bid he had been initially placed on units bid metformin was held on admission and the patient was placed on a sliding scale short acting insulin in addition to above metformin given the patient s need for weeks of prednisone therapy to treat his pericarditis was consulted to provide input regarding adequate glucose control while on steroids during this time the team recommended adding units of homolog with a humalog pen before meals this dose was deemed appropriate to help control blood sugars while on prednisone and also safe enough to be continued after the steroid taper has finished paroxysmal atrial fibrillation patient in sinus rhythm upon admission the patient s home metoprolol was continued for rate control the patient s home rivaroxaban was mg unclear why patient on this dose but he has been maintained on mg daily since at least the end of given the patient s normal kidney function at baseline the dose was increased to mg daily prior to discharge in order to ensure adequate anticoagulation for atrial fibrillation chronic issues cll patient presented with leukocytosis to the setting of his underlying cll he takes ibrutinib as an outpatient which has been controlling his symptoms this medication was unfortunately not on formulary at his wife was able to bring in his home ibrutinib to take while hospitalized acyclovir was continued at his home dose chronic pain patient is taking a number of medications at home to treat chronic pain in the shoulders as well as in his back we continued all of these medications while he is in the hospital hypothyroidism continued home levothyroxine insomnia continued home ramelteon trazodone ziprasidone hld continued home atorvastatin and fenofibrate transitional issues patient hospitalized for chest pain without evidence of ischemic disease troponin and stress test both unremarkable ekg notable for diffuse ste consistent with presumptive diagnosis of idiopathic acute pericarditis patient placed on prednisone taper rather than nsaids given history of cad and possible history of gib he was also started on colchicine which will be continued as an outpatient patient seen by team for better blood sugar control and they recommended starting units of humalog before meals rivaroxaban dose increased to mg daily from mg daily given no contraindication to do so and mg subtherapeutic anticoagulation for patient s with atrial fibrillation needs to have cbc monitored closely after discharge to make sure h h stable on higher dose new medications homolog pen units prior to meals colchicine mg po ng bid for months prednisone taper as follows mg daily on the day of discharge and the following day then mg daily for days then mg daily for days then mg daily for days then off changed medications rivaroxaban changed from mg daily to mg daily stopped medications none relevant lab values on discharge wbc hgb cre bun na glu contact son code status full medications on admission the preadmission medication list is accurate and complete acetaminophen mg po q8h prn pain mild acyclovir mg po q8h atorvastatin mg po qpm divalproex extended release mg po qam divalproex extended release mg po qpm docusate sodium mg po bid constipation fenofibrate mg po daily fluoxetine mg po daily gabapentin mg po tid hydrocodone acetaminophen 5mg 325mg tab po q8h prn pain moderate levothyroxine sodium mcg po daily lidocaine patch ptch td qam losartan potassium mg po daily metoprolol tartrate mg po bid pantoprazole mg po q24h senna mg po bid prn constipation ziprasidone hydrochloride mg po bid melatonin mg oral qhs prn magnesium oxide mg po bid metformin glucophage mg po bid prochlorperazine mg po q6h prn nausea vomiting furosemide mg po daily aspirin mg po daily clonidine mg po tid ibrutinib mg oral daily rivaroxaban mg po daily sucralfate gm po tid prn upset stomach with meals multivitamins tab po daily fluticasone propionate nasal spry nu bid belsomra suvorexant oral qhs prn insomnia trazodone mg po qhs prn insomnia glargine units breakfast glargine units bedtime discharge medications colchicine mg po bid rx colchicine mg tablet s by mouth twice a day disp tablet refills glargine units breakfast glargine units bedtime humalog units breakfast humalog units lunch humalog units dinner rx insulin glargine lantus unit ml as dir sc units before bkft units before bed disp vial refills rx insulin lispro humalog kwikpen unit ml as dir sc units before bkft units before lnch units before dinr disp syringe refills prednisone mg po daily duration dose you will take your last mg tablet of prednisone the day after leaving the hospital this is dose of tapered doses rx prednisone mg tablet s by mouth once a day disp tablet refills prednisone mg po daily duration doses take this dose after finishing the last mg tablet this is dose of tapered doses rx prednisone mg tablet s by mouth once a day disp tablet refills prednisone mg po daily duration doses take this dose after finishing the last mg tablet this is dose of tapered doses rx prednisone mg tablet s by mouth once a day disp tablet refills prednisone mg po daily duration doses take this dose after finishing the last mg tablet this is dose of tapered doses rx prednisone mg tablet s by mouth once a day disp tablet refills rivaroxaban mg po dinner rx rivaroxaban xarelto mg tablet s by mouth once a day disp tablet refills acetaminophen mg po q8h prn pain mild acyclovir mg po q8h aspirin mg po daily atorvastatin mg po qpm belsomra suvorexant oral qhs prn insomnia clonidine mg po tid divalproex extended release mg po qam divalproex extended release mg po qpm docusate sodium mg po bid constipation fenofibrate mg po daily fluoxetine mg po daily fluticasone propionate nasal spry nu bid furosemide mg po daily gabapentin mg po tid hydrocodone acetaminophen 5mg 325mg tab po q8h prn pain moderate ibrutinib mg oral daily levothyroxine sodium mcg po daily lidocaine patch ptch td qam losartan potassium mg po daily magnesium oxide mg po bid melatonin mg oral qhs prn metformin glucophage mg po bid metoprolol tartrate mg po bid multivitamins tab po daily pantoprazole mg po q24h prochlorperazine mg po q6h prn nausea vomiting senna mg po bid prn constipation sucralfate gm po tid prn upset stomach with meals trazodone mg po qhs prn insomnia ziprasidone hydrochloride mg po bid discharge disposition home discharge diagnosis primary acute pericarditis type dm secondary cll sick sinus syndrome s p pacemaker cad s p des htn discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear was a pleasure taking care of you at why were you in the hospital you came to the hospital because of chest pain in the center of your chest this pain became severe enough to make it difficult for you to breathe what happened in the hospital you had laboratory tests which showed that you were not having a heart attack you had an ekg to look at the electrical activity of your heart this showed that you may have inflammation of the lining around the heart called the pericardium you were given medications to control your pain and started on steroids to reduce the inflammation of the pericardium you were seen by the diabetes doctor in order to better control your blood sugar while on the steroids your kidney s were injured while in the hospital this was likely caused by taking off too much fluid your kidney function improved by the time you left the hospital you also had a stress test to assess the blood vessels surrounding your heart muscle this was normal what should you do after leaving the hospital you should take all of your medications as prescribed you should follow up with your primary care doctor you should follow up with at dr office on at am we wish you the best your care team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies penicillins nsaids non steroidal anti inflammatory drug erythromycin base cheeses soft cottage cream cheese attending chief complaint chest pain major surgical or invasive procedure none history of present illness mr is a with h o cll on ibrutinib metastatic testicular cancer cad s p mid lad pci in sss s p pacemaker paroxysmal atrial fibrillation on rivaroxaban and diabetes mellitus with recent pericarditis admission from who presented with chest pain and was found to be hypotensive requiring icu admission prior to presentation to the on he had substernal chest pain he was taken to the imaging including bedside echocardiogram unremarkable cta without evidence of pulmonary embolus his systolic blood pressure dropped to s and he was transferred to the in the he was seen by cardiology who felt his picture was most consistent with septic shock given fever of he had relative hypotension in this setting which was fluid responsive he had continued tachycardia while in the so he was admitted to the icu in the icu he was weaned off bipap and breathing on room air his blood pressure recovered and tachycardia improved with reintroduction of metoprolol at home dose of mg tid blood and urine cultures sent and given fever he was empirically started on vancomycin cefepime while awaiting culture results his rivaroxaban was held in the setting of worsening kidney function of note during his recent admission from he had midsternal chest pain with diffuse st elevations echocardiogram demonstrated trivial pericardial effusion so a presumptive diagnosis of pericarditis he was treated with colchicine and prednisone with improvement in his chest pain although the patient continued to have episodes of pain up to discharge he was discharged on colchicine with prednisone taper he also had a recent admission in where he had a gi bleed thought to be due to combination of ibrutinib clopidogrel and rivaroxaban his clopidogrel was ultimately discontinued there is also a remark about a vitreous hemorrhage occurring due to ibrutinib on transfer patient noted ongoing stable chest pain improved with oxycodone he had mild shortness of breath but no new cough he had no acute complaints and denied fever chills abdominal pain constipation swelling past medical history past oncological history cll 17p and stage iiia mixed germ cell tumor of the testis lymphocytosis incidentally found during a psychiatric hospitalization ct scan showed a slightly enlarged spleen at cm and no adenopathy he met with dr in at wbc was with lymphocytes hgb and platelets flow cytometry was consistent with cll and b cell gene rearrangement confirmed clonality cll fish panel showed a p53 mutation he was asymptomatic at the time of diagnosis and followed with dr gradually uptrended to in in in and on hgb has decreased slightly to and hct with platelets on the labs hematology care transitioned to dr after dr he also started having nightly sweats ct chest without lymphadenopathy or other notable findings initial hematology evaluation for second opinion wbc hgb hct plt peripheral blood flow cytometry and cytogenetics confirmed cll with tp53 deletion ct abdomen pelvis without lymphadenopathy or other notable findings started ibrutinib mg daily ibrutinib held for vitreous bleed ibrutinib restarted per osh records underwent scrotal u s showing heterogeneous left testicle prominent rete testis on right presented to his outpatient hematologist dr a painful swollen left testicle swelling over months worsening pain this had been evaluated on with an ultrasound that did not demonstrate torsion but did show heterogeneous morphology of the left testicle hcg was positive referred to dr underwent left radical orchiectomy pathology revealed cm malignant mixed germ cell tumor of the testis embryonal carcinoma teratoma yolk sac tumor choriocarcinoma invading hilar statin vaginalis with lymphatic vascular invasion and metastatic tumor nodules in the spermatic cord pt2nxs1 although no post orch levels beta hcg on up from on afp ldh normal ct torso showing new mm nodule in the left lower lobe and comparison with ct left para aortic lymphadenopathy up to cm and a cm fluid collection in the left inguinal region scrotum felt to be likely postsurgical c1d1 ep c2d1 ep delayed week after nasal infection admitted for weakness fall admitted for parainfluenza pneumonia symptomatic anemia palpitations developed nausea vomiting in hospital c3d1 ep delayed week added palonosetron c4d1 ep ct torso with significant decrease in size of the previously seen left para aortic lymph node which now measures mm previously mm otherwise no lad restarted ibrutinib for recurrent cll night sweats lymphocytosis other pmh sick sinus syndrome s p ppm revo ddd mri compatible cad s p des to mid lad in preserved lvef in stroke diabetes mellitus type ii on insulin hypertension hyperlipidemia morbid obesity s p gastric bypass surgery obstructive sleep apnea not on cpap pancreatitis related to alcohol hypothyroidism osteoarthritis major depression with psychotic features vs schizoaffective disorder per patient dr name unknown affiliated with anxiety conversion disorder benign paroxysmal positional vertigo glaucoma cataract dr at s p cholecystectomy s p bilateral shoulder surgery chronic pain social history family history no known family history of malignancies physical exam on transfer to omed service general middle aged white man sitting up in chair comfortably a ox3 vitals t hr bp rr o2 sat on ra heent sclera anicteric mmm oropharynx clear neck jvp not elevated no lad lungs clear to auscultation bilaterally no wheezes rales rhonchi cv irregularly irregular normal s1 s2 no murmurs rubs gallops chest moderate tenderness with palpation of sternum abd soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema skin no ras neuro patient responding to questions appropriately and is able to move all four extremities at discharge general in nad sitting in chair vitals t 9f bp hr rr o2 sat on ra discharge weight kg lb heent nc at sclera anicteric mmm oropharynx clear jvp elevation not appreciated lungs ctab no wheezing cv regular normal s1 s2 no murmurs rubs gallops chest right sided port in place abd soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext bilateral pitting edema r l up to knees pulses neuro a ox3 moving all extremities with purpose pertinent results 55am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 55am blood neuts bands monos eos baso myelos absneut abslymp absmono abseos absbaso 55am blood glucose urean creat na k cl hco3 angap 25pm blood probnp 55am blood calcium phos mg uricacd 33pm blood osmolal 55am blood tsh cxr new left pleural effusion with subjacent opacities which may reflect atelectasis and or consolidation ct chest w out contrast new small bilateral pleural effusions and adjacent consolidations at the lung bases left greater than right likely representing atelectasis however superimposed infection is difficult to exclude new moderate pericardial effusion echocardiogram the estimated right atrial pressure is at least mmhg due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded overall left ventricular systolic function is normal lvef there is beat to beat variability of the left ventricular ejection fraction due to an irregular rhythm premature beats the aortic valve leaflets are mildly thickened trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is moderate pulmonary artery systolic hypertension there is a trivial physiologic pericardial effusion impression focused study suboptimal image quality lv function appears preserved moderate pulmonary hypertension trivial pericardial effusion compared with the prior study images reviewed of the rhythm is now afib and hr higher pericardial effusion very slighlty larger however still trivial echocardiogram the left ventricular cavity size is normal overall left ventricular systolic function is normal lvef the aortic valve leaflets are mildly thickened there is a small to moderate sized circumferential pericardial effusion there is right ventricular diastolic collapse consistent with impaired fillling tamponade physiology but no respiratory eccentuatlon of transmitral flow a left pleural effusion is present compared with the prior study images reviewed of the pericardial effusion is now larger and increased pericardial pressure is now suggested pericardiocentesis under us fluoro ecg and hemo guidance and after local anesthesia the pericardial space was entered using tuhioy needle initial pericardial pressure was markedly elevated and after removing ml of bloody fluid pressure became negative with improvement in bp and rapid wean of pressors pericardial fluid negative for malignant cells abundant blood lymphocytes histiocytes and mesothelial cells head ct study is mildly to moderately motion degraded despite multiple acquisitions within this confine there is no evidence of acute infarction hemorrhage edema or mass effect there is prominence of the ventricles and sulci suggestive of involutional changes multiple periventricular hypodensities probably sequela of chronic small vessel disease there are atherosclerotic calcifications of the carotid siphon and the vertebral arteries bilaterally there is no evidence of fracture the visualized portion of the paranasal sinuses is unremarkable there is mild opacification of the mastoid air cells the middle ear cavities are remarkable the visualized portion of the orbits are unremarkable impression within confines of a mildly to moderately motion degraded examination no evidence of acute intracranial abnormality on noncontrast head ct specifically no large territory infarct or intracranial hemorrhage additional findings described above echocardiogram limited study focused views suboptimal image quality overall left ventricular systolic function is normal lvef there is abnormal septal motion position the number of aortic valve leaflets cannot be determined trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is a trivial physiologic pericardial effusion compared with the prior study images reviewed of the pericardial effusion has nearly resolved echocardiogram very limited study due to suboptimal image quality there is a very small posterior pericardial effusion there are no echocardiographic signs of tamponade compared with the prior study images reviewed of no obvious change but the technically suboptimal nature of both studies precludes definitive comparison other pertinent labs 36am blood ck mb ctropnt probnp 19am blood crp 33pm blood crp 40pm blood micro all blood and urine cultures were negative discharge labs 08am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 08am blood plt 08am blood glucose urean creat na k cl hco3 angap 08am blood alt ast alkphos totbili 08am blood calcium phos mg brief hospital course this is a yo man with h o cll on ibrutinib metastatic testicular cancer cad s p mid lad des in sss now s p pacemaker paroxysmal atrial fibrillation on rivaroxaban diabetes mellitus and recent admissions for gi bleed and subsequently pericarditis discharged on prednisone who re presented with chest pain he was admitted to f icu for atrial fibrillation with rapid ventricular rate fever and hypotension he was treated with cefepime for hap and was transferred to cardiology for treatment of ongoing pericarditis he was started on high dose aspirin which improved his pericarditis pain unfortunately this was complicated by hemopericardium and hypotension for which he required ccu transfer and pericardial drainage he was then transferred back to the cardiology service on prednisone for his pericarditis and prior to discharge anticoagulation was resumed his ibrutinib was not restarted per his outpatient oncologist active issues pericarditis pericardial effusion patient with recent hospitalization for pericarditis on colchicine and prednisone taper returned with ongoing chest pain with exertion which was same in quality etiology of effusion presumed viral vs malignancy he was started on aspirin mg tid this was complicated by pericardial effusion for which he was admitted to ccu following pericardiocentesis cc bloody fluid was removed via the pericardial drain chest pain resolved by end of admission and on discharge in discussion with patient s oncologist dr ibrutinib was discontinued as it increased his bleeding risk while on aspirin and rivaroxaban patient was continued on colchicine and prednisone continued pantoprazole mg daily for gi prophylaxis colchicine should be continued for months after patient will need prednisone taper recommend tapering to mg for weeks before stopping after patient sees cardiologist on transaminitis unclear etiology of abnormal lfts in the 2000s that developed in ccu no new medications viral hepatitis panel negative these could represent decreased perfusion vs shock liver his acetaminophen fenofibrate and statin were held his transaminases improved but remained elevate and will need monitoring as outpatient to confirm values normalize baseline creatinine but increased to this likely reflects pre renal physiology in the setting of hypotension and improved after pericardial fluid drained creatinine improved to at discharge acute on chronic diastolic heart failure repeat echo with intact lvef and evidence of pulmonary hypertension likely secondary to osa bilateral pulmonary effusions on ct chest with likely dry weight of increased to on admission patient continued on home furosemide mg daily then reduced to furosemide mg every other day as his weight remained stable home losartan was restarted at a reduced dose of mg daily discharge weight kg lb atrial fibrillation patient developed atrial fibrillation with rapid ventricular rate increased to 120s metoprolol was increased to q6hr then consolidated to metoprolol succinate xl mg daily after ibrutinib was stopped patient was restarted on rivaroxaban mg daily cad s p lad pci aspirin was held in setting of hemorrhagic pericardial effusion aspirin mg daily restarted after ibrutinib was stopped for prevention of stent thrombosis mid lad des from on held atorvastatin given elevated lfts polyuria unclear precipitant no recent changes in medications patient reports he has recently begun drinking copious amounts of h2o upon initiation of ibrutinib ibrutinib was stopped unlikely diabetes insipidus given concentrated urine electrolytes osmolol this also this occurred in the setting of hyperglycemia with some glycosuria was consulted for improved glucose control see below diabetes mellitus followed while patient was on hospital diet he was managed with lantus units qam with humalog coverage with meals and iss per recommendations discharged on home diabetic regimen this was communicated with elderly services osa patient reports he has a cpap mask at night for osa but does not use it he was given bipap in vbg at the time was oxygen saturations improved to high on ra sats remained normal without cpap at night schizoaffective disorder continued divalproic acid fluoxetine ziprosadone followed qtc cll per oncologist stopped ibrutinib patient has follow up with oncology resolved issues altered mental status this occurred in the setting of hypotension however high risk of cva given anticoagulation stat head ct head negative mental status improved hyponatremia component of hyperglycemia as well as true hyponatremia suspect related to hypervolemia improved with fluid restriction hospital acquired pneumonia ct chest with bilateral pleural effusions as well as consolidations concerning for hap in setting of fever and hypotension on presentation he was treated with cefepime transitional issues patient s ibrutinib was stopped cll management per oncologist patient needs repeat tte to re evaluate pericardial effusion within weeks patient s home losartan was restarted at lower dose please monitor bp and uptitrate as tolerated patient s home metoprolol tartrate was switched to metoprolol succinate xl mg daily patient s home clonidine mg tid was stopped due to hypotension and altered mental status please monitor anxiety agitation and resume as needed patient restarted on aspirin mg to prevent thrombosis of his mid lad drug eluting stent and rivaroxaban mg daily for embolic prevention in setting of paroxysmal atrial fibrillation please continue to monitor for bleeding patient s home furosemide was adjusted to mg every other day please monitor volume status and weight increase as needed patient discharged on prednisone mg daily and colchicine mg bid for pericarditis he was not continued on high dose nsaids aspirin because of bleeding while on aspirin mg tid he should continue the colchicine for months after start date and prednisone until follow up with his cardiologist on at that time recommend tapering to prednisone mg for weeks before stopping please monitor lfts and confirm they normalize patient s atorvastatin fenofibrate acetaminophen were held on discharge in the setting of elevated lfts please recheck liver function tests at next follow up appointment and restart his atorvastatin and fenofibrate if they are normal please continue to monitor patient s cbc wbc and hgb abnormal likely due to cll but remained stable on discharge admission weight kg discharge weight kg abnormal labs on discharge alt ast wbc hgb code status full code contact name of health care proxy son phone medications on admission the preadmission medication list is accurate and complete acyclovir mg po q8h aspirin mg po daily atorvastatin mg po qpm divalproex extended release mg po qam divalproex extended release mg po qpm docusate sodium mg po bid constipation fenofibrate mg po daily fluticasone propionate nasal spry nu bid gabapentin mg po tid hydrocodone acetaminophen 5mg 325mg tab po q8h prn pain moderate levothyroxine sodium mcg po daily lidocaine patch ptch td qam losartan potassium mg po daily magnesium oxide mg po bid metoprolol tartrate mg po tid multivitamins tab po daily pantoprazole mg po q24h prochlorperazine mg po q6h prn nausea vomiting rivaroxaban mg po dinner senna mg po bid prn constipation sucralfate gm po tid prn upset stomach with meals trazodone mg po qhs prn insomnia ziprasidone hydrochloride mg po bid colchicine mg po bid prednisone mg po daily this is dose of tapered doses prednisone mg po daily this is dose of tapered doses prednisone mg po daily this is dose of tapered doses prednisone mg po daily this is dose of tapered doses furosemide mg po daily ibrutinib mg oral daily melatonin mg oral qhs prn fluoxetine mg po daily acetaminophen mg po q8h prn pain mild glargine units breakfast glargine units bedtime humalog units breakfast humalog units lunch humalog units dinner clonidine mg po tid discharge medications metoprolol succinate xl mg po daily furosemide mg po every other day losartan potassium mg po daily acyclovir mg po q8h aspirin mg po daily colchicine mg po bid divalproex extended release mg po qam divalproex extended release mg po qpm docusate sodium mg po bid constipation fluoxetine mg po daily fluticasone propionate nasal spry nu bid gabapentin mg po tid hydrocodone acetaminophen 5mg 325mg tab po q8h prn pain moderate glargine units breakfast glargine units bedtime insulin sc sliding scale using hum insulin levothyroxine sodium mcg po daily lidocaine patch ptch td qam magnesium oxide mg po bid melatonin mg oral qhs prn multivitamins tab po daily pantoprazole mg po q24h prednisone mg po daily please continue until follow up with your pcp is dose of tapered doses rivaroxaban mg po dinner senna mg po bid prn constipation sucralfate gm po tid prn upset stomach with meals trazodone mg po qhs prn insomnia ziprasidone hydrochloride mg po bid held acetaminophen mg po q8h prn pain mild this medication was held do not restart acetaminophen until you follow up with your pcp held atorvastatin mg po qpm this medication was held do not restart atorvastatin until you follow up with pcp held clonidine mg po tid this medication was held do not restart clonidine until you follow up with your pcp held fenofibrate mg po daily this medication was held do not restart fenofibrate until you follow up with your pcp home with service facility discharge diagnosis healthcare associated pneumonia pericarditis hemorrhage pericardial effusion with tamponade physiology paroxysmal atrial fibrillation long term use of anticoagulants acute on chronic left ventricular diastolic heart failure polyuria type diabetes mellitus on insulin with acute kidney injury chronic lymphocytic leukemia delirium coronary artery disease with prior stenting elevated hepatic transaminases hyponatremia obstructive sleep apnea schizoaffective disorder discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr it was a pleasure taking care of your why were you in the hospital he will brought to the emergency room due to low blood pressures you were also found to have a fever and there was concern that you had an infection what happened in the hospital because of your low blood pressures you were initially brought to the intensive care unit there your breathing improved and your blood pressure came up you were started on antibiotics for possible infection you were also found to have extra fluid likely due to heart failure you were given iv medications to remove this extra fluid and your breathing improved the swelling in your legs also improved transferred to the cardiology floor for further treatment of your pericarditis inflammation around your heart for this you were treated with high dose aspirin and your pain in the chest greatly improved unfortunately you had some bleeding in the sac around your heart and you had to go to the icu again to have a drain placed in that sac to remove the fluid when the drain was removed you returned to the cardiology floor and we continued your prednisone for your pericarditis you had no more chest pain and your rivaroxaban and aspirin were restarted in discussion with your oncologist dr decision was made to stop your ibrutinib what should you do after leaving the hospital you should take all of your medications as prescribed you should weigh yourself when you get home and then daily and call your doctor if you note weight gain more than pounds you should follow up with your doctors as listed below we wish you the best your care team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies penicillins nsaids non steroidal anti inflammatory drug erythromycin base cheeses soft cottage cream cheese attending chief complaint chest pain major surgical or invasive procedure none history of present illness with pmhx coronary artery disease status post stent heart failure with preserved ejection fraction atrial fibrillation on rivaroxaban and a recent admission for pericarditis who presents with a chief complaint of substernal chest pain that began suddenly at in the morning on it is similar to his previous presentation of pericarditis patient was recently in the hospital for weeks for a pericarditis flare he was discharged on and felt very well throughout the weekend on he was getting up from bed to go to the bathroom when he felt the sudden onset of sharp substernal chest pain with radiation around to both shoulders and through to the back patient describes the pain as similar to his prior pericarditis flare the patient had been taking vicodin and a prednisone taper at home this did not help with his pain his pain is exacerbated by taking a deep breath it is not made worse by positional changes he denies any associated symptoms of shortness of breath or syncope he did report palpitations on and for this reason he called ems to return to the emergency department in the ed initial vs were t bp hr rr o2 on ra exam notable for ga nad sitting up in bed pulm ctab cv nl s1s2 rrr no m r g peripheral pulses b l abd soft nt nd no masses ext non pitting lle ekg nsr71 nl axis nl intervals non specific st changes labs showed negative troponin leukocytosis to baseline in the to mid teens urinary glucose greater than sodium up to on recheck imaging showed cxr pa and lateral small left pleural effusion with overlying atelectasis left base consolidation is difficult to exclude consults cardiology recommended mg p o prednisone to continue home colchicine and admit to patient received mg morphine sulfate tylenol g prednisone mg normal saline l zofran mg iv transfer vs were t bp hr rr o2 on ra on arrival to the floor patient reports the above history he is very uncomfortable and would like a shot of morphine again as it works faster for the pain he denies any fevers chills abdominal pain dysuria hematuria and focal weakness review of systems point ros reviewed and negative except as per hpi past medical history sick sinus syndrome s p ppm revo ddd mri compatible cad s p des to mid lad in preserved lvef in stroke with recovering motor function though still with some left thigh sensory decrease diabetes mellitus type ii on insulin hypertension hyperlipidemia morbid obesity s p gastric bypass surgery obstructive sleep apnea not on cpap pancreatitis related to alcohol s p cholecystectomy hypothyroidism osteoarthritis s p bilateral shoulder surgery chronic pain major depression with psychotic features vs schizoaffective disorder per patient dr name unknown affiliated with anxiety conversion disorder benign paroxysmal positional vertigo glaucoma cataract dr at social history family history no known history of malignancies physical exam admission physical exam vs temp po bp hr rr o2 sat o2 delivery ra dyspnea rass pain score general obese caucasian male sitting up in bed and responsive pleasant and cooperative though appears somewhat uncomfortable heent sclerae anicteric mucous members moist heart distant heart sounds but regular rate and rhythm normal s1 s2 no murmurs gallops rubs thorax put in place in right upper chest wall lungs patient takes short shallow breaths no wheezes rales rhonchi abdomen abdomen is soft protuberant nontender in all quadrants no rebound guarding extremities no cyanosis clubbing trace pretibial edema one third of the way up the shin pulses dp pulses bilaterally neuro a ox3 moving all extremities with purpose skin warm and well perfused patient has a cm x cm brown raised flat lesion in between his shoulder blades on the back he states this was from a mole being lanced when i was a teenager now surrounding skin changes discharge physical exam vs hr data last updated temp tm bp hr rr o2 sat o2 delivery ra wt lb kg general obese caucasian male sitting in chair pleasant eating breakfast heent sclerae anicteric mucous members moist heart distant heart sounds but regular rate and rhythm pre cordial rub pain reproducible on palpation lungs breathing comfortably on ra ctab abdomen abdomen is soft protuberant nontender in all quadrants no rebound guarding extremities no cyanosis clubbing pitting edema bilaterally neuro a ox3 moving all extremities with purpose skin patient has a cm x cm brown raised flat lesion in between his shoulder blades on the back he states this was from a mole being lanced when i was a teenager now surrounding skin changes pertinent results admission labs 03pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 03pm blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 03pm blood hypochr normal anisocy normal poiklo normal macrocy normal microcy normal polychr normal 03pm blood ptt 03pm blood glucose urean creat na k cl hco3 angap 59am blood alt ast alkphos totbili 03pm blood ctropnt 59am blood ck mb ctropnt 59am blood albumin calcium phos mg 59am blood cortsol 59am blood tsh 59am blood osmolal 11pm blood lactate discharge physical exam 36am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 36am blood ptt 36am blood glucose urean creat na k cl hco3 angap 36am blood calcium phos mg studies tte suboptimal image quality trivial posterior pericardial effusion without echo evidence of tamponade aortic regurgitation is present mildly dilated thoracic aorta mild left ventricular hypertrophy with normal biventricular systolic function findings c w hypertensive heart disease a left pleural effusion is present compared with the prior study images reviewed of the pericardial effusion is likley similar this was a complete study with additional findings as noted but still limited by image quality brief hospital course gentleman with a history of coronary artery disease status post mid lad pci in sick sinus syndrome status post pacemaker paroxysmal atrial fibrillation on rivaroxaban type diabetes mellitus on insulin and recent admission for pericarditis who presented with substernal chest pain similar to his most recent admission with pericarditis patient s exam generally unremarkable with normal blood pressures and good mentation labs notable for a negative troponin and ekg without acute changes hospital course complicated by hyponatremia hyperkalemia and hyperglycemia active issues chest pain pericarditis his chest pain on presentation was very similar to his most recent presentation of pericarditis in the absence of troponin elevation and ekg changes this was likely a recurrent pericarditis flare no evidence of recurrent pericardial effusion on tte he was recently discharged on a prednisone taper and taking mg daily prior to admission the patient received prednisone mg in the emergency room on with plan to continue prednisone mg daily for days followed by a slower steroid taper pantoprazole was continued for gi prophylaxis given persistently recurring chest pain and inability to give nsaids in the setting of cad status post pci aspirin was increased to mg daily for weeks with plan for subsequent decrease back to mg daily the patient may continue taking mg daily for pain as needed colchicine twice daily was continued chest pain resolved within day of admission follow up with cardiology is recommended hyponatremia the patient presented with hypoosmolar hyponatremia to which was asymptomatic exacerbated by initial blood glucose of urine lytes were notable for na of given euvolemia on exam his hyponatremia was most likely secondary to siadh in the setting of acute pain from pericarditis a m cortisol level low in the setting of current treatment with prednisone as above tsh not significantly elevated patient was placed on fluid restriction of l daily and his sodium subsequently increased to the patient was educated to continue with the daily fluid restriction until he follows up with his primary care physician follow up within weeks is recommended to ensure normalization of hyponatremia discharge serum sodium hyperkalemia the patient s potassium during his hospital stay was increased to asymptomatic etiology remains unclear hyperlipidemia as below possibly contributing no evidence of acute kidney injury potassium normalized to his baseline with treatment of hypoglycemia as below discharge serum potassium type ii diabetes mellitus insulin dependent hyperlipidemia patient was initially continued on his home insulin regimen with units of glargine twice daily plus an insulin sliding scale however his blood sugars are persistently elevated to with the increased prednisone dose was consulted to assist with further management recommended an increase of his insulin sliding scale his glargine was changed to qam and 30qhs due to hypoglycemia with sliding scale with meals he received diabetes education and was discharged with a glucometer his home one was broken for daily blood sugar measurement and instructions to monitor his bg closely as his prednisone tapered acute on chronic diastolic heart failure mildly hyperkalemic on presentation he was given an additional dose of mg iv lasix with good urine output his home lasix was increased to mg every day discharge weigth 4kg lbs increased lasix mg to daily continued metoprolol succinate xl mg po daily continued rivaroxaban mg p o with dinner chronic stable issues cad status post lad pci continue baby aspirin obstructive sleep apnea history of schizoaffective disorder home divalproex fluoxetine ziprasidone cll his ibrutinib was stopped on the last hospital stay given bleeding risk and pericardial effusion continued to hold ibrutinib transitional issues aspirin increased to mg daily for pain control plan to decrease back to mg daily weeks after discharge discharge serum sodium uptrending discharged on fluid restriction please follow up within weeks after discharge to ensure resolution discharge potassium increased lasix to 20mg daily discharge weigth 4kg lbs increased insulin sliding scale and decreased glargine to 30u patient given glucometer for daily blood sugar measurement please follow up and adjust insulin regimen accordingly code full confirmed contact wife son and listed hcp medications on admission the preadmission medication list is accurate and complete colchicine mg po bid divalproex extended release mg po qam divalproex extended release mg po qpm docusate sodium mg po bid constipation fluoxetine mg po daily fluticasone propionate nasal spry nu daily prn nasal congestion gabapentin mg po tid levothyroxine sodium mcg po daily lidocaine patch ptch td qam multivitamins tab po daily pantoprazole mg po q24h senna mg po bid prn constipation ziprasidone hydrochloride mg po bid acyclovir mg po q8h aspirin mg po daily furosemide mg po every other day rivaroxaban mg po dinner trazodone mg po qhs prn insomnia sucralfate gm po tid prn upset stomach with meals melatonin mg oral qhs prn magnesium oxide mg po bid hydrocodone acetaminophen 5mg 325mg tab po q8h prn pain moderate acetaminophen mg po q8h prn pain mild prednisone mg po daily this is dose of tapered doses metoprolol succinate xl mg po daily losartan potassium mg po daily glargine units breakfast glargine units bedtime insulin sc sliding scale using hum insulin discharge medications prednisone mg po daily duration days take for four days starting rx prednisone mg tablet s by mouth daily disp tablet refills prednisone mg po daily duration days take for days starting rx prednisone mg tablet s by mouth daily disp tablet refills prednisone mg po daily duration days take for days starting rx prednisone mg tablet s by mouth daily disp tablet refills prednisone mg po daily duration days take for days starting rx prednisone mg tablet s by mouth daily disp tablet refills prednisone mg po daily duration days take for days starting rx prednisone mg tablet s by mouth daily disp tablet refills aspirin mg po daily rx aspirin mg tablet s by mouth daily disp tablet refills glargine units breakfast glargine units bedtime insulin sc sliding scale using hum insulin acetaminophen mg po q8h prn pain mild acyclovir mg po q8h colchicine mg po bid divalproex extended release mg po qam divalproex extended release mg po qpm docusate sodium mg po bid constipation fluoxetine mg po daily fluticasone propionate nasal spry nu daily prn nasal congestion furosemide mg po every other day gabapentin mg po tid hydrocodone acetaminophen 5mg 325mg tab po q8h prn pain moderate levothyroxine sodium mcg po daily lidocaine patch ptch td qam losartan potassium mg po daily magnesium oxide mg po bid melatonin mg oral qhs prn metoprolol succinate xl mg po daily multivitamins tab po daily pantoprazole mg po q24h rivaroxaban mg po dinner senna mg po bid prn constipation sucralfate gm po tid prn upset stomach with meals trazodone mg po qhs prn insomnia ziprasidone hydrochloride mg po bid discharge disposition home discharge diagnosis primary diagnosis pericarditis secondary diagnoses hyponatremia acute on chronic diastolic heart failure cad status post lad pci type diabetes mellitus obstructive sleep apnea history of schizoaffective disorder cll 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 had worsening of your chest pain from the pericarditis your steroid dose and your aspirin were increased imaging of your heart did not show any evidence of recurrent fluid around your heart your salt level was low this was likely because of you were drinking a lot of water the amount of water you were drinking per day was decreased and your salt levels increased your blood sugar was high and therefore your insulin was increased what should i do after discharge please take all the medications as detailed below specifically take 325mg aspirin daily for the next two weeks after that you should go back to 81mg daily a baby aspirin but you can take daily if you still have pain for up to two more weeks please do not drink more than 5l of fluid per day until you see your pcp to keep your salt levels steady please use the glucometer to measure your blood sugar daily and record the results please show them to your pcp when you follow up with him please call your pcp if your blood sugars are or for assistance with changing your insulin dose please follow up with your pcp and your cardiologist as below all the best your care team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies penicillins nsaids non steroidal anti inflammatory drug erythromycin base cheeses soft cottage cream cheese attending chief complaint fever cough major surgical or invasive procedure none history of present illness mr is a male with history of cll atrial fibrillation on rivaroxaban cad s p stent recurrent pericarditis and hfpef who presents cough and fever patient awoke at 4am on morning with fever to sweats and a non productive cough took tylenol and fever improved to but in the afternoon spiked another fever he also reports associated sore throat he reports good po intake he notes shortness of breath as well as right lateral rib pain with coughing his wife was sick with similar symptoms recently but no other sick contacts he had his flu shot this year he reports he was originally scheduled to be admitted to start his new chemotherapy but he was postponed till due to difficulty getting the new medication he called his oncologist who recommended he come to the ed for evaluation on arrival to the ed initial vitals were ra exam notable for anxious appearing lung clear without accessory muscle use and benign abdomen labs were notable for wbc h h plt na k bun cr and lactate influenza pcr negative blood cultures were sent cxr was negative for pneumonia patient was given tylenol po prior to transfer vitals were 2l on arrival to the floor patient reports an mild headache he denies vision changes dizziness lightheadedness weakness numbness hemoptysis chest pain palpitations abdominal pain nausea vomiting diarrhea hematemesis hematochezia melena dysuria hematuria and new rashes past medical history past oncologic history cll 17p and stage iiia mixed germ cell tumor of the testis lymphocytosis incidentally found during a psychiatric hospitalization ct scan showed a slightly enlarged spleen at cm and no adenopathy he met with dr in at wbc was with lymphocytes hgb and platelets flow cytometry was consistent with cll and b cell gene rearrangement confirmed clonality cll fish panel showed a p53 mutation he was asymptomatic at the time of diagnosis and followed with dr wbc gradually uptrended to in in in and on hgb has decreased slightly to and hct with platelets on the labs hematology care transitioned to dr after dr he also started having nightly sweats ct chest without lymphadenopathy or other notable findings initial hematology evaluation for second opinion wbc hgb hct plt peripheral blood flow cytometry and cytogenetics confirmed cll with tp53 deletion ct abdomen pelvis without lymphadenopathy or other notable findings started ibrutinib mg daily ibrutinib held for vitreous bleed ibrutinib restarted per osh records underwent scrotal u s showing heterogeneous left testicle prominent rete testis on right presented to his outpatient hematologist dr a painful swollen left testicle swelling over months worsening pain this had been evaluated on with an ultrasound that did not demonstrate torsion but did show heterogeneous morphology of the left testicle hcg was positive referred to dr underwent left radical orchiectomy pathology revealed cm malignant mixed germ cell tumor of the testis embryonal carcinoma teratoma yolk sac tumor choriocarcinoma invading hilar statin vaginalis with lymphatic vascular invasion and metastatic tumor nodules in the spermatic cord pt2nxs1 although no post orch levels beta hcg on up from on afp ldh normal ct torso showing new mm nodule in the left lower lobe and comparison with ct left para aortic lymphadenopathy up to cm and a cm fluid collection in the left inguinal region scrotum felt to be likely postsurgical c1d1 ep c2d1 ep delayed week after nasal infection admitted for weakness fall admitted for parainfluenza pneumonia symptomatic anemia palpitations developed nausea vomiting in hospital c3d1 ep delayed week added palonosetron c4d1 ep ct torso with significant decrease in size of the previously seen left para aortic lymph node which now measures mm previously mm otherwise no lad restarted ibrutinib for recurrent cll night sweats lymphocytosis past medical history sick sinus syndrome s p ppm revo ddd mri compatible cad s p des to mid lad in preserved lvef in stroke with recovering motor function though still with some left thigh sensory decrease diabetes mellitus type ii on insulin hypertension hyperlipidemia morbid obesity s p gastric bypass surgery obstructive sleep apnea not on cpap pancreatitis related to alcohol s p cholecystectomy hypothyroidism osteoarthritis s p bilateral shoulder surgery chronic pain major depression with psychotic features vs schizoaffective disorder per patient dr name unknown affiliated with anxiety conversion disorder benign paroxysmal positional vertigo glaucoma cataract dr at social history family history no known history of malignancies physical exam admission physical examination vs temp bp hr rr o2 sat ra general pleasant man in no distress sitting up in chair comfortably heent anicteric perll op clear cardiac rrr normal s1 s2 no m r g lung appears in no respiratory distress decreased breath sounds abd obese soft non tender non distended positive bowel sounds ext warm well perfused no lower extremity edema erythema or tenderness neuro a ox3 good attention and linear thought cn ii xii intact strength full throughout sensation to light touch intact skin no significant rashes access right chest wall port without erythema discharge physical examination vs temp tm bp hr rr o2 sat o2 delivery ra general sitting comfortably in chair no acute distress heent no conjunctival pallor anicteric sclera mmm oropharynx clear neck supple non tender jvp just above clavicle cv rrr s1 and s2 normal no murmurs rubs gallops resp ctab no wheezes crackles breathing comfortably soft non tender obese non distended bs normoactive extremities warm well perfused trace lower extremity edema neuro a o x3 grossly intact skin no skin rashes lesions access right sided port clean dry and intact without surrounding erythema pertinent results admission labs 50pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 50pm blood neuts bands lymphs monos eos baso myelos absneut abslymp absmono abseos absbaso 50pm blood glucose urean creat na k cl hco3 angap 50pm blood lactate micro flu a b pcr negative blood culture blood culture rapid respiratory viral screen culture respiratory viral culture negative respiratory viral antigen screen negative for respiratory viral antigen specimen screened for adeno parainfluenza influenza a b and rsv by immunofluorescence blood culture source line poc blood culture urine culture urine culture yeast cfu ml imaging reports cxr right sided port a cath tip terminates in the low svc left sided dual chamber pacemaker device is again noted with leads in unchanged positions cardiac silhouette size remains mildly enlarged the mediastinal and hilar contours are unchanged pulmonary vasculature is normal no focal consolidation pleural effusion or pneumothorax is demonstrated previously noted small left pleural effusion appears resolved no acute osseous abnormalities demonstrated tte the left atrium is normal in size the estimated right atrial pressure is mmhg there is mild symmetric left ventricular hypertrophy with normal cavity size due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded there is mild global left ventricular hypokinesis lvef right ventricular chamber size is normal with mild global free wall hypokinesis the aortic root is mildly dilated at the sinus level the ascending aorta is mildly dilated the aortic valve leaflets are mildly thickened there is no aortic valve stenosis mild aortic regurgitation is seen the mitral valve leaflets are not well seen there is mild pulmonary artery systolic hypertension there is a small pericardial effusion the effusion is echo dense consistent with blood inflammation or other cellular elements there are no echocardiographic signs of tamponade or constriction cxr in comparison with the study of there are slightly lower lung volumes continued enlargement the cardiac silhouette with dual channel pacer in place right ij port a cath is unchanged note focal pneumonia vascular congestion or pleural effusion other labs 45am blood igg 30am blood lactate 22am blood probnp 35pm blood osmolal 22am blood tsh 56pm blood lactate discharge labs 28pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 28pm blood neuts bands monos eos baso atyps myelos absneut abslymp absmono abseos absbaso 28pm blood glucose urean creat na k cl hco3 angap 28pm blood alt ast ld ldh alkphos totbili 28pm blood calcium phos mg with a background history of cll previously on ibrutinib status post ep x4 cycles and now planned for venetoclax sss status post ppm placement af on rivaroxaban cad status post stent recurrent pericarditis hfpef stroke htn hld and hypothyroidism presenting with cough and fever acute active issues fever non productive cough presented with one day history of fever sore throat intermittent dry cough general body aches and mild shortness of breath wife with similar symptoms in the days preceding symptoms which had subsequently resolved patient had flu vaccine this season took tylenol with some improvement in fever but given persistence greater than 3f presented to ed examination with clear lungs bilaterally and no evidence of fluid overload labs were unremarkable cxr without evidence of infiltrates consolidation as symptoms were most likely consistent with a viral syndrome patient was treated symptomatically and started on five day course of levofloxacin to prevent bacterial superinfection total igg levels influenza swab negative and respiratory viral culture negative symptoms gradually improved and resolved over the course of the admission patient left ama understanding all risks to him leaving uti baseline creatinine acute rise prior to transfer to ficu with poor urine output over the previous hours most likely etiology included pre renal vs atn in the setting of hypovolemia and hypotension however patient was on many medications which could have precipitated including colchicine losartan and acyclovir these medications were held but restarted prior to discharge as creatinine returned to baseline following administration of 2l ivf in ficu patient also noted to have dirty ua with subsequent urine culture positive for yeast cfu ml started fluconazole 200mg daily for days patient left ama understanding all risks to him leaving atrial flutter patient with a background history of atrial fibrillation flutter with rvr on previous admission required transfer to ccu for rate management in the setting of pericardial effusion and subsequent tamponade requiring pericardiocentesis flipped into atrial flutter with rates 150s on minimal response to po iv diltiazem and po metoprolol patient remained asymptomatic but given hypotension with systolic blood pressure readings in the patient was transferred to icu for rate control here he received 2l ivf and was loaded with iv amiodarone with subsequent normalization of rates and pressures remained stable on the floor on fractionated metoprolol 5mg q6h before transitioning to home regimen of metoprolol succinate 150mg daily prior to discharge cll lymphocytosis diagnosed in unfavorable cytogenetics by virtue of deletion 17p previously on ibrutinib and has completed four cycles of ep but now off ibritnib therapy given recent admission for pericardial effusion and hypotension patient was scheduled for admission to initiate therapy with venetoclax this was deferred given current infective process and will be commenced at a later date continued home acyclovir for prophylaxis chronic stable issues type ii diabetes mellitus continued home insulin glargine regimen but eased back on humalog iss on admission blood sugars remained controlled hfref continued furosemide 20mg every other day initially for preload reduction and losartan 25mg daily for afterload reduction however given acute rise in creatinine on furosemide and losartan were both held nhbk was initially achieved with fractionated metoprolol but given atrial flutter changes were made as above given normalization of creatinine and heart rates patient was transitioned back to the above medications prior to discharge atrial fibrillation continued rivaroxaban while inpatient temporarily transitioned to heparin drip given acute rise in creatinine but restarted rivaroxaban with improvement in renal function rate control management was achieved with control of atrial flutter as above before transitioning back to home regimen of metoprolol cad status post lad pci hyperlipidemia patient was transitioned back to aspirin 81mg daily from aspirin 325mg daily given resolution of pericarditis symptoms atorvastatin and fenofibrate had been held on a previous admission the decision if when to restart these is deferred to outpatient providers pericarditis continued prednisone taper but changed colchicine bid to daily dosing hypertension continued home losartan initially before it was held in the setting of restarted prior to discharge schizoaffective disorder continued home divalproex fluoxetine and ziprasidone hyponatremia stable and chronic thought to be some component of siadh sodium levels were closely monitored during admission and patient was maintained on a low sodium diet anemia chronic and stable likely due to malignancy hypothyroidism continued home levothyroxine 50mcg daily transitional issues discharge wbc discharge hgb discharge plt discharge na discharge k discharge creatinine medication changes fluconazole 200mg daily for days levofloxacin 750mg one dose changed aspirin to 81mg daily changed colchicine to 6mg daily follow up with oncologist dr week follow up when to start venetoclax re check tfts in six weeks to ensure correct dose of levothyroxine decide if when to restart atorvastatin fenofibrate repeat ekg with pcp at next visit to assess rhythm discuss chronic pain management at next pcp visit given concern patient is pain is not adequately controlled patient left ama code status full contact hcp son medications on admission acetaminophen mg po q8h prn pain mild fever acyclovir mg po q8h aspirin mg po daily colchicine mg po bid divalproex extended release mg po qam divalproex extended release mg po qpm fluoxetine mg po daily furosemide mg po every other day gabapentin mg po tid lidocaine patch ptch td daily prn back pain multivitamins tab po daily pantoprazole mg po q24h rivaroxaban mg po dinner senna mg po bid hydrocodone acetaminophen 5mg 325mg tab po q8h prn pain moderate losartan potassium mg po daily magnesium oxide mg po bid metoprolol succinate xl mg po daily prednisone mg po daily glargine units breakfast glargine units bedtime insulin sc sliding scale using hum insulin docusate sodium mg po bid fluticasone propionate nasal spry nu daily prn nasal congestion melatonin mg oral qhs prn levothyroxine sodium mcg po daily trazodone mg po qhs prn insomnia ziprasidone hydrochloride mg po bid discharge medications fluconazole mg po q24h duration doses rx fluconazole mg tablet s by mouth daily disp tablet refills levofloxacin mg po q24h duration dose rx levofloxacin mg tablet s by mouth once disp tablet refills aspirin mg po daily rx aspirin mg tablet s by mouth daily disp tablet refills colchicine mg po daily rx colchicine mg tablet s by mouth daily disp tablet refills glargine units breakfast glargine units bedtime insulin sc sliding scale using hum insulin acyclovir mg po q8h divalproex extended release mg po qam divalproex extended release mg po qpm docusate sodium mg po bid fluoxetine mg po daily fluticasone propionate nasal spry nu daily prn nasal congestion furosemide mg po every other day gabapentin mg po tid hydrocodone acetaminophen 5mg 325mg tab po q8h prn pain moderate levothyroxine sodium mcg po daily lidocaine patch ptch td daily prn back pain losartan potassium mg po daily magnesium oxide mg po bid metoprolol succinate xl mg po daily multivitamins tab po daily pantoprazole mg po q24h prednisone mg po daily duration doses tapered dose down rivaroxaban mg po dinner senna mg po bid prn constipation ziprasidone hydrochloride mg po bid discharge disposition home with service facility discharge diagnosis viral bronchitis acute kidney injury yeast urinary tract infection atrial flutter with rvr and hypotension cll discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr you decided to leave the hospital against medical advice we wanted you to stay as you had evidence of a yeast urinary tract infection but you were not willing to do this you understood the risks including death and severe infection but still wanted to leave although you are leaving against medical advice it is important you follow the below instructions we will give you a prescription and you must pick these up in the morning if you develop fevers burning when you urinate pain in your abdomen racing heart chest pain or shortness of breath you should return to the ed why you came to the hospital you were admitted to the hospital with fevers cough generalized body aches and right sided rib pain what happened while you were in the hospital you tested negative for flu so your symptoms likely represented a viral infection we treated you with antibiotics to prevent pneumonia you developed a rapid heart rate and low blood pressures requiring transfer to the icu for management of same when your heart rate and blood pressure returned to normal you were transferred back to the floor you were found to have a urinary tract infection which you will need to take medication to treat when you are discharged what you need to do when you leave the hospital you need to take all your medications as prescribed follow up with dr as arranged you will start your cll treatment at a later date keep a close eye on your weight and restrict your salt and fluid intake your team medication changes fluconazole 200mg daily for days levofloxacin 750mg one dose changed aspirin to 81mg daily changed colchicine to 6mg daily followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies penicillins nsaids non steroidal anti inflammatory drug erythromycin base cheeses soft cottage cream cheese attending chief complaint initiation of venetoclax major surgical or invasive procedure none history of present illness with a background history of cll previously on ibrutinib status post ep x4 cycles and now planned for venetoclax sss status post ppm placement af on rivaroxaban cad status post stent recurrent pericarditis hfpef stroke htn hld and hypothyroidism presenting for initiation of venetoclax therapy patient with recent admission with viral respiratory illness and negative infectious work up admission was complicated by atrial flutter with rvr requiring icu admission for iv amiodarone load which was likely pre renal in origin in the setting of hypovolemia and hypotension and yeast urinary tract infection for which he was prescribed a two week course of fluconazole also completed course of levofloxacin for cap prophylaxis unfortunately he left against medical advice the night prior to discharge since discharge patient has been doing well all symptoms from previous viral respiratory illness have resolved except for persistence of non productive cough recalls episodes of loose stools over the weekend but this has now resolved does report anxiety regarding starting new chemotherapy regimen especially regarding kidney dysfunction and future need for dialysis had long discussion with dr same denies fevers chills headache light headedness dizziness sore throat nasal congestion sputum production wheeze chest pain palpitations abdominal pain discomfort diarrhea constipation pr blood loss joint pains or skin rashes does have chronic right shoulder pain point review of systems negative except as noted above past medical history past oncologic history cll 17p and stage iiia mixed germ cell tumor of the testis lymphocytosis incidentally found during a psychiatric hospitalization ct scan showed a slightly enlarged spleen at cm and no adenopathy he met with dr in at wbc was with lymphocytes hgb and platelets flow cytometry was consistent with cll and b cell gene rearrangement confirmed clonality cll fish panel showed a p53 mutation he was asymptomatic at the time of diagnosis and followed with dr wbc gradually uptrended to in in in and on hgb has decreased slightly to and hct with platelets on the labs hematology care transitioned to dr after dr he also started having nightly sweats ct chest without lymphadenopathy or other notable findings initial hematology evaluation for second opinion wbc hgb hct plt peripheral blood flow cytometry and cytogenetics confirmed cll with tp53 deletion ct abdomen pelvis without lymphadenopathy or other notable findings started ibrutinib mg daily ibrutinib held for vitreous bleed ibrutinib restarted per osh records underwent scrotal u s showing heterogeneous left testicle prominent rete testis on right presented to his outpatient hematologist dr a painful swollen left testicle swelling over months worsening pain this had been evaluated on with an ultrasound that did not demonstrate torsion but did show heterogeneous morphology of the left testicle hcg was positive referred to dr underwent left radical orchiectomy pathology revealed cm malignant mixed germ cell tumor of the testis embryonal carcinoma teratoma yolk sac tumor choriocarcinoma invading hilar statin vaginalis with lymphatic vascular invasion and metastatic tumor nodules in the spermatic cord pt2nxs1 although no post orch levels beta hcg on up from on afp ldh normal ct torso showing new mm nodule in the left lower lobe and comparison with ct left para aortic lymphadenopathy up to cm and a cm fluid collection in the left inguinal region scrotum felt to be likely postsurgical c1d1 ep c2d1 ep delayed week after nasal infection admitted for weakness fall admitted for parainfluenza pneumonia symptomatic anemia palpitations developed nausea vomiting in hospital c3d1 ep delayed week added palonosetron c4d1 ep ct torso with significant decrease in size of the previously seen left para aortic lymph node which now measures mm previously mm otherwise no lad restarted ibrutinib for recurrent cll night sweats lymphocytosis past medical history sick sinus syndrome s p ppm revo ddd mri compatible cad s p des to mid lad stroke with recovering motor function though still with some left thigh sensory decrease type ii dm on insulin hypertension hyperlipidemia morbid obesity status post gastric bypass surgery osa not on cpap pancreatitis secondary to alcohol cholecystectomy hypothyroidism osteoarthritis bilateral shoulder surgery chronic pain right shoulder major depression with psychotic features anxiety conversion disorder benign paroxysmal positional vertigo glaucoma social history family history no known history of malignancies physical exam admission physical examination vs temp bp hr manual rr sao2 ra general sitting comfortably in chair no acute distress heent at nc eomi perrla no conjunctival pallor anicteric sclera mmm oropharynx without lesions neck supple non tender no lad no jvd cv rrr s1 and s2 normal no murmurs rubs gallops resp ctab no wheezes crackles breathing comfortably without use of accessory muscles of respiration obese soft non tender distention with body habitus bs normoactive extremities warm well perfused lower extremity edema neuro a o x3 cn ii xii intact strength in all extremities sensation intact skin no skin rashes lesions access right sided port clean dry and intact without surrounding erythema discharge physical examination vs temp tm bp hr rr o2 sat o2 delivery ra general sitting comfortably in chair no acute distress heent no conjunctival pallor anicteric sclera mmm oropharynx without lesions neck supple non tender no lad no jvd cv rrr s1 and s2 normal no murmurs rubs gallops resp decreased air entry at left base present previously no clear crackles breathing comfortably without use of accessory muscles of respiration obese soft non tender distention with body habitus bs normoactive extremities warm well perfused lower extremity edema neuro a o x3 grossly intact skin no skin rashes lesions access right sided port clean dry and intact without surrounding erythema pertinent results admission labs 30pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30pm blood neuts bands monos eos baso myelos absneut abslymp absmono abseos absbaso 30pm blood urean creat na k cl hco3 angap 30pm blood alt ast ld ldh ck cpk alkphos totbili 30pm blood albumin calcium phos mg uricacd 30pm blood hba1c eag other pertinent labs 00am blood 00am blood 04am blood tsh 04am blood free t4 04am blood osmolal 12pm blood osmolal 14am blood 14am blood osmolal 14am blood cortsol 48pm blood aspergillus galactomannan antigen negative 48pm blood b glucan negative 00am blood 02pm blood bnzodzp neg 02pm blood acetmnp neg 05pm blood g6pd normal 05pm blood ret aut abs ret 05pm blood lmwh 05pm blood heparin 30am blood cortsol micro urine culture x3 no growth blood culture x4 no growth respiratory viral screen culture negative imaging reports cxr lungs are low volume with bibasilar atelectasis left sided pacemaker is unchanged right sided port a cath tip projects to the cavoatrial junction small left pleural effusion stable no pneumothorax is seen there is subsegmental atelectasis in the left lung base ct chest without contrast bilateral pleural effusions left greater than right slightly increased in volume since the prior study moderate sized pericardial effusion also slightly increased in volume since the prior study left sided pacemaker and right sided central line unchanged bibasilar atelectasis renal us no hydronephrosis on either side corticomedullary differentiation is well maintained ct head without contrast no acute intracranial process tte due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded overall left ventricular systolic function is normal lvef there is a small pericardial effusion the effusion is echo dense consistent with blood inflammation or other cellular elements discharge labs 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood neuts bands lymphs monos eos baso myelos other absneut abslymp absmono abseos absbaso 00am blood ptt 00am blood glucose urean creat na k cl hco3 angap 00am blood alt ast ld ldh alkphos totbili 00am blood calcium phos mg uricacd with a background history of cll previously on ibrutinib status post ep x4 cycles and now planned for venetoclax sss status post ppm placement af on rivaroxaban cad status post stent recurrent pericarditis hfpef stroke htn hld and hypothyroidism presenting for initiation of venetoclax therapy acute active issues hyponatremia patient with a known history of chronic hyponatremia previously thought to contain a component of siadh sodium levels remained an issue throughout admission acutely decreased in the setting of ivf administration reaching a nadir of urine serum lytes and osmolality consistent with siadh of note patient is on several psychiatric medications which may contribute to chronic hyponatremia rapid correction of sodium with iv furosemide with daily diuresis required to maintain sodium am cortisol was within normal limits as patient required ivf during initiation of venetoclax sodium was closely monitored and high dose iv furosemide administered twice daily patient was also fluid restricted and placed on a low sodium diet weight down trended over the course of the admission but was still elevated at discharge will increase home regimen of furosemide to 20mg po daily from every other day sodium prior to discharge but this lab was drawn prior to last dose of iv furosemide 80mg cll diagnosed in unfavorable cytogenetics by virtue of deletion 17p previously on ibrutinib but now off ibrutinib therapy given recent admission for pericardial effusion and hypotension presented on this occasion to initiate venetoclax however starting same was delayed in the setting of hyponatremia and altered mental status eventually started venetoclax 20mg daily on without issue or evidence of tls dose was increased to 50mg on and 100mg on without any issues continued allopurinol renally dosed during to prevent hyperuricemia also continued acyclovir for hsv prophylaxis bradycardia patient with a known history of sick sinus syndrome with a ppm in place and atrial fibrillation on metoprolol succinate 150mg daily soon after admission patient was noted to have heart rates in on monitor which persisted for several hours ekg at the time with normal heart rate in patient was asymptomatic with the exception of a mechanical fall without injury initially rates recovered to but following administration of metoprolol tartrate 5mg rates dropped back down to ep were consulted interrogation of the ppm revealed a well functioning device with no documented bradycardic episodes subsequent telemetry with high pvc burden and ventricular bigeminy but no recurrence of bradycardia these episodes likely represented monitoring error rather than true bradycardia fever patient with temperature of and subsequently on remained asymptomatic and denied all symptoms ct chest demonstrated bilateral pleural effusions left greater than right but no evidence of consolidation infiltration urine culture was negative beta glucan and galactomannan were not detected respiratory screen and culture also negative unclear exact etiology but given absence of recurrent fevers and hemodynamic stability antibiotics were not initiated patient with apparent baseline creatinine over the course of admission creatinine fluctuated reaching a max of on most likely etiology was venous congestion in the setting volume overload creatinine returned to baseline on each occasion following aggressive diuresis consistent with this hypothesis somnolence intermittent somnolence noted by nursing staff over the course of admission unclear etiology initial concern was for osmotic demyelination in setting of rapid hyponatremia correction but this was unlikely given normal neurological examination and periods of time when he was alert awake and orientated another concern was patient self medicating with vicodin as was found on two occasions with vicodin on his person although patient denied same serum apap level was negative and no respiratory depression was noted most likely etiology was delirium in setting of metabolic derangements lue swelling patient noted to have left greater than right upper extremity swelling by nursing unclear exact chronicity but a small difference was notable on examination had been anticoagulated on rivaroxaban at home and before transitioning to enoxaparin while an inpatient factor xa levels were therapeutic patient refused us doppler there was no further change in swelling throughout admission making dvt less likely chronic stable issues type ii diabetes mellitus continued home insulin glargine with a humalog insulin sliding scale adjustments had to be made on a number of occasions given patient s reluctance to eat a restricted diet will be discharged on admission regimen hfref issues with volume persisted throughout admission and were contributors to both and hyponatremia home furosemide was replaced with iv furosemide as needed ultimately the patient was transitioned to an oral regimen of furosemide 20mg daily weight was not at admission weight at discharge but as it was the patient s birthday and he was stable we were happy to discharge him with close follow up losartan was held in the setting of and will be held on discharge the decision if when to restart is deferred to outpatient providers metoprolol fractionated from home dose was continued except as noted above atrial fibrillation rivaroxaban was held given potential interaction with venetoclax and therapeutic enoxaparin started in its place home metoprolol was fractionated and continued at 5mg q6h except as noted above following discussion the decision was made to restart rivaroxaban on discharge as the risk of further thromboembolism was felt to outweigh the risk of bleeding cad status post lad pci hyperlipidemia continues aspirin 81mg daily on previous admission both statin and fenofibrate were held decision if when to restart these medications is deferred to outpatient provider pericarditis colchicine was discontinued given theoretical interaction with venetoclax hypertension home losartan 25mg daily was held in the setting of labile renal function during the course of admission it was held on discharge decision if when to restart is deferred to outpatient providers schizoaffective disorder cotninued home divalproex fluoxetine and ziprasidone discussion should be had with outpatient psychiatrist if these medications may be contributing to chronic hyponatremia anemia chronic issue which remained stable during admission required two blood transfusions while an inpatient most likely etiology is malignancy induced hypothyroidism continued levothyroxine 50mcg daily repeat tsh was with a normal free t4 discussed with endocrinology who recommended repeating tsh after to obtain an accurate reflection if current dosing is correct chronic pain continued gabapentin 300mg tid dose adjusted during times of acute kidney injury home vicodin was replaced with apap and oxycodone while an inpatient will be discharged on gabapentin 300mg bid renally dosed transitional issues discharge wbc discharge hgb discharge plt discharge na discharge k discharge creatinine discharge calcium discharge phosphate discharge uric acid admission weight 1lbs discharge weight 9lbs medication changes started allopurinol daily started venetoclax 100mg daily dose will be changed by dr started ondansetron 4mg q8h prn tablets changed gabapentin to 300mg twice a day changed furosemide to 20mg daily held losartan as your blood pressures were normal stopped colchicine given interaction with venetoclax stopped fluconazole as it was no longer needed repeat tsh after to determine if levothyroxine is adequately dosed discuss if chronic siadh may be attributable to psychiatric medications held losartan at discharge as blood pressures were within normal limits decision if when to restart deferred to outpatient providers follow patient s weight closely as not at baseline on discharge decision if when to restart atorvastatin fenofibrate is deferred to outpatient providers code status full contact hcp son medications on admission lidocaine patch ptch td daily prn back pain acyclovir mg po q8h aspirin mg po daily colchicine mg po daily divalproex extended release mg po qam divalproex extended release mg po qpm fluoxetine mg po daily fluticasone propionate nasal spry nu daily prn nasal congestion furosemide mg po every other day gabapentin mg po tid levothyroxine sodium mcg po daily losartan potassium mg po daily metoprolol succinate xl mg po daily multivitamins tab po daily pantoprazole mg po q24h rivaroxaban mg po dinner senna mg po bid prn constipation ziprasidone hydrochloride mg po bid fluconazole mg po q24h docusate sodium mg po bid hydrocodone acetaminophen 5mg 325mg tab po q8h prn pain moderate magnesium oxide mg po bid glargine units breakfast glargine units bedtime insulin sc sliding scale using hum insulin discharge medications allopurinol mg po daily rx allopurinol mg tablet s by mouth daily disp tablet refills furosemide mg po daily rx furosemide mg tablet s by mouth daily disp tablet refills ondansetron mg po q8h prn nausea rx ondansetron mg tablet s by mouth q8h prn disp tablet refills venetoclax mg oral daily gabapentin mg po bid glargine units breakfast glargine units bedtime insulin sc sliding scale using hum insulin acyclovir mg po q8h aspirin mg po daily divalproex extended release mg po qam divalproex extended release mg po qpm docusate sodium mg po bid fluoxetine mg po daily fluticasone propionate nasal spry nu daily prn nasal congestion hydrocodone acetaminophen 5mg 325mg tab po q8h prn pain moderate levothyroxine sodium mcg po daily lidocaine patch ptch td daily prn back pain magnesium oxide mg po bid metoprolol succinate xl mg po daily multivitamins tab po daily pantoprazole mg po q24h rivaroxaban mg po dinner senna mg po bid prn constipation ziprasidone hydrochloride mg po bid held losartan potassium mg po daily this medication was held do not restart losartan potassium until informed by your outpatient provider home with service facility discharge diagnosis primary diagnoses chronic lymphocytic leukemia hypervolemic hyponatremia acute kidney injury acute on chronic anemia secondary diagnoses type ii diabetes mellitus heart failure with reduced ejection fraction atrial fibrillation coronary artery disease status post percutaneous coronary intervention hyperlipidemia recurrent pericarditis hypertension schizoaffective disorder hypothyroidism discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear mr why you came to the hospital you were admitted to start chemotherapy for your cll what happened while you were in hospital you had problems with low sodium levels due to excess fluid in your body we restricted your salt fluid intake and gave you diuretics to remove the extra fluid you were confused for several days likely due to your low sodium levels you also had a fever but all this was negative and they did not recur we started your chemotherapy and increased the dose to 100mg without issue what you need to do when you leave the hospital you need to follow up with dr please take all your medications as prescribed it is important to try to limit your fluid intake to 2l a day and eat a low salt diet it is also important you measure your weight daily to assess for fluid retention it was a pleasure taking care of you your healthcare team medication changes started allopurinol daily started venetoclax 100mg daily dose will be changed by dr started ondansetron 4mg every hours as needed for nausea changed gabapentin to 300mg twice a day changed furosemide to 20mg daily held losartan as your blood pressures were normal stopped colchicine given interaction with venetoclax stopped fluconazole as it was no longer needed followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies penicillins nsaids non steroidal anti inflammatory drug erythromycin base cheeses soft cottage cream cheese attending chief complaint l sided weakness and numbness in face arm leg major surgical or invasive procedure none history of present illness mr is a man with cll on venclexta hx testicular cancer diabetes hypertension hyperlipidemia obesity right subcortical stroke in with residual left leg weakness ambulates with a cane remote bpv sick sinus syndrome status post pacemaker depression with psychotic features presenting with vertigo near falls vision changes he describes near constant vertigo worse with position changes and several near syncopal events starting morning symptoms initially improved that evening but when he woke up on felt significantly worse he had no associated nausea or vomiting but was taking reduced p o water only minimal food due to concern that he would become nauseous and be at risk for falling while going to the bathroom on he called the on call physician for his insurance and was advised to go to the ed to be evaluated however he did not because he had just put in a freestyle monitor and was worried that they would take it out if he needed a scan he paid for this out of pocket he did however call his wife from whom he is separated and went to stay with her due to continuing symptoms on he went to urgent care his vitals were unremarkable and his exam was notable for almost falling off of his chair with extraocular movement check his finger nose finger was notable for past pointing bilaterally and he had binocular double vision he was sent to the ed by ambulance for further work up he reports that while getting into the ambulance from he developed left arm and leg weakness and numbness on arrival to the emergency room a rapid response was called due to concern for stroke he had hypoglycemia to a an amp of dextrose after his blood sugar improved to and left arm weakness and numbness improved however his leg still is paralyzed ct head was negative for an acute bleed cta head and neck had no thrombus labs notable for wbc hemoglobin platelets inr ptt bun hold blood sodium k3 chloride bicarb creatinine troponin negative lactate ast alt alk phos t bili albumin negative serum tox for asa ethanol acetaminophen tca imaging notable for negative cta head and ct brain perfusion scan copied below wet read the patient was given amp dextrose hydrocodone acetaminophen p o x2 which she reports was ineffective vitals prior to transfer heart rate blood pressure respiratory rate satting on room air glucose upon arrival to the floor the patient confirms the above history he additionally describes some dyspnea on exertion that has been long standing and which he attributes to his wife s smoke a complete review of systems was negative except for as noted in the hpi specifically he denies lightheadedness headache chest pain palpitations abdominal pain constipation dysuria rash joint pain of note in and he had an external work up for left arm weakness concerning for possible tias unrevealing for an embolic disorders past medical history past oncologic history cll 17p and stage iiia mixed germ cell tumor of the testis lymphocytosis incidentally found during a psychiatric hospitalization ct scan showed a slightly enlarged spleen at cm and no adenopathy he met with dr in at wbc was with lymphocytes hgb and platelets flow cytometry was consistent with cll and b cell gene rearrangement confirmed clonality cll fish panel showed a p53 mutation he was asymptomatic at the time of diagnosis and followed with dr wbc gradually uptrended to in in in and on hgb has decreased slightly to and hct with platelets on the labs hematology care transitioned to dr after dr he also started having nightly sweats ct chest without lymphadenopathy or other notable findings initial hematology evaluation for second opinion wbc hgb hct plt peripheral blood flow cytometry and cytogenetics confirmed cll with tp53 deletion ct abdomen pelvis without lymphadenopathy or other notable findings started ibrutinib mg daily ibrutinib held for vitreous bleed ibrutinib restarted per osh records underwent scrotal u s showing heterogeneous left testicle prominent rete testis on right presented to his outpatient hematologist dr a painful swollen left testicle swelling over months worsening pain this had been evaluated on with an ultrasound that did not demonstrate torsion but did show heterogeneous morphology of the left testicle hcg was positive referred to dr underwent left radical orchiectomy pathology revealed cm malignant mixed germ cell tumor of the testis embryonal carcinoma teratoma yolk sac tumor choriocarcinoma invading hilar statin vaginalis with lymphatic vascular invasion and metastatic tumor nodules in the spermatic cord pt2nxs1 although no post orch levels beta hcg on up from on afp ldh normal ct torso showing new mm nodule in the left lower lobe and comparison with ct left para aortic lymphadenopathy up to cm and a cm fluid collection in the left inguinal region scrotum felt to be likely postsurgical c1d1 ep c2d1 ep delayed week after nasal infection admitted for weakness fall admitted for parainfluenza pneumonia symptomatic anemia palpitations developed nausea vomiting in hospital c3d1 ep delayed week added palonosetron c4d1 ep ct torso with significant decrease in size of the previously seen left para aortic lymph node which now measures mm previously mm otherwise no lad restarted ibrutinib for recurrent cll night sweats lymphocytosis past medical history sick sinus syndrome s p ppm revo ddd mri compatible cad s p des to mid lad stroke with recovering motor function though still with some left thigh sensory decrease type ii dm on insulin hypertension hyperlipidemia morbid obesity status post gastric bypass surgery osa not on cpap pancreatitis secondary to alcohol cholecystectomy hypothyroidism osteoarthritis bilateral shoulder surgery chronic pain right shoulder major depression with psychotic features anxiety conversion disorder benign paroxysmal positional vertigo glaucoma social history family history no known history of malignancies physical exam admission physical exam vs pulse heart rate respiratory rate satting on room air general obese man sitting comfortably in bed fully conversant heent pupils mm reactive to light no scleral icterus moist mucous membranes without any lesions neck no lymphadenopathy cv regular rate and rhythm without murmurs pulm clear to auscultation bilaterally with good air movement throughout and no adventitious sounds abd obese nondistended nontender cannot assess organomegaly several ecchymoses at insulin sites ext warm well perfused pitting edema to knees bilaterally skin no concerning rashes or lesions neuro alert oriented telling cogent history no speech abnormalities cranial nerves left homonymous hemianopia on visual field testing did not assess blink to threat unable to do left lateral gaze with either eye when asked symmetric v1 through v3 sensation bilaterally symmetric eyes squeeze bite puffed cheeks hearing normal hearing aids in place tongue midline no palate deviation shrug symmetric strength moving left arm against gravity out of strength in all muscle groups compared to out of on the right unable to lift left leg against gravity on command sensation of upper extremities symmetric reports absent sensation to light touch in all fields of the left leg compared to right does not feel pinprick on the left leg trouble following command for finger nose finger but no obvious dysmetria psych slightly odd affect but overall appropriate access port discharge physical exam physical exam hr data last updated temp pt refused vitals tm bp hr rr o2 sat o2 delivery ra wt lb kg general obese man sitting comfortably in chair conversant neuro alert with fluent speech eomi no scleral icterus moist mucous membranes without any lesions symmetric smile pronator drift on l with eyes closed ue strength and sensation motor at hip motor elsewhere no sensation at lle motor sensation rle was observed to walk from bathroom later in the morning stable but slow gait neck no lymphadenopathy no subclav lad cv regular rate and rhythm distant heart sounds pulm clear to auscultation bilaterally with good air movement distant abd obese nondistended nontender excoriations on r side ext warm well perfused edema to mid shin skin no concerning rashes or lesions psych linear thought mood anxious access port pertinent results admission labs 20pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 20pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 20pm blood ptt 20pm blood urean 20pm blood alt ast alkphos totbili 20pm blood ctropnt 20pm blood albumin 00am blood vitb12 00am blood tsh 00am blood free t4 20pm blood asa neg ethanol neg acetmnp neg tricycl neg 23pm blood glucose lactate creat na k cl calhco3 pertinent imaging and micro head ct no evidence for acute intracranial hemorrhage or acute major vascular territorial infarction ct perfusion ml area of t max seconds and mismatch project over the left periatrial white matter and left lateral ventricle possibly an artifact if clinically indicated mri would be more sensitive for the detection of acute infarct cta no carotid stenosis by nascet criteria atherosclerosis of intracranial carotid and intracranial vertebral arteries without flow limiting stenosis ossification of the posterior longitudinal ligament in the upper cervical spine narrows the spinal canal as seen on the prior cervical spine ct from mri head w wo contrast no evidence of infarction hemorrhage mass or edema discharge labs 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood glucose urean creat na k cl hco3 angap 00am blood alt ast ld ldh alkphos totbili 00am blood calcium phos mg uricacd brief hospital course mr is a man with high risk cll on venetoclax insulin dependent type diabetes history of left sided cerebrovascular accident depression with psychotic features reported history of conversion disorder hypothyroidism hypertension who was admitted with left sided weakness and diminished sensation in the setting of hypoglycemia and days of vertigo ct head negative cta head and neck with no thrombus on admission mri brain performed without acute findings his symptoms gradually resolved over the course of his stay and he was discharged with outpatient transitional issues follow up hypothyroidism levothyroxine dose increase from 75mcg to 100mcg after lab findings of elevated tsh and low free t4 needs repeat tsh ft4 in weeks follow up on neurological symptoms his l sided weakness and sensory deficits had resolved by time of discharge f u blood glucose he was discharged on his home at meals with iss per for his mri his freestyle was removed he may require replacement as an outpatient follow up re bppv symptoms follow up re l forearm hand peripheral neuropathy alleviated by capsaicin cream he was continued on gabapentin 600mg bid as an inpatient follow up on joint tailbone pain exacerbated by poor weather follow up uric acid level he was given dose of allopurinol at discharge after his am labs showed uric acid will need repeat level at next appointment discharge weight 296lbs 134kg increased throughout hospitalization follow up weight consider increasing dose of daily lasix if needed acute issues l sided weakness numbness l homonymous hemianopsia h o prior cva presented with left sided weakness and diminished sensation no acute stroke was seen on ct cta imaging despite what would be a large territory infarct given profound ipsilateral facial and upper and lower extremity symptoms neurology was consulted and had low suspicion for new event hypoglycemia was considered as this can cause recrudescence of stroke symptoms however his symptoms persisted even with correction of blood sugar b12 and tsh t4 were also obtained he was noted to be somewhat hypothyroid even with medications and we increased his dosage from 75mcg to 100mcg he was placed on telemetry no events were noted with approval from our ep team and his outpatient cardiologist an mri brain was performed with read notable for no evidence of infarction hemorrhage mass or edema he continued to work with our team his symptoms gradually resolved throughout his stay with full upper extremity strength at discharge and waxing waning ability to walk on his lle there was low concern for an acute stroke or tia the primary team neurology and psychiatry found that his presentation is most consistent with functional neurologic disorder with possible recrudescence of stroke symptoms given hypoglycemia and low thyroid he should follow up as an outpatient for further management of symptoms hypoglycemia in setting of insulin dependent type diabetes mellitus his a1c in was his home insulin regimen is units times daily he was reportedly taking in much less p o in the setting of his persistent vertigo which may explain his hypoglycemia no symptoms of other common causes of hypoglycemia eg infection or adrenal insufficiency were found no insulin was given on admission and he was started on of his dose the next morning was consulted and his insulin regimen was adjusted per their recommendations his home metformin was held but restarted on discharge his discharge regimen was home at meals with iss per anxiety psychiatry was consulted regarding his increasing anxiety and were also made aware of his ongoing symptoms potentially contributing to his anxiety he was given lorazepam prn for acute anxiety events diabetic neuropathy he noted exacerbation of l sided neuropathy from fingers to mid forearm he was given capsaicin cream prn to good effect and did not note further symptoms throughout the rest of his stay he also continued on his home gabapentin bppv he noted worsening vertigo the day prior to discharge similar but reduced in intensity as compared to previous events he noted that he had been given meclizine prior to good effect he stated that he felt okay to move around with the main symptom being that he saw double if something was held close to his face he was given meclizine he was able to ambulate without issues at time of discharge chronic issues depression he was continued on home ziprasidone cll he brought in his venetoclax from home and was continued on his regimen he was given allopurinol on discharge given a slight increase in uric acid levels htn continued on home losartan and metoprolol he was also continued on home furosemide with furosemide prn for edema and increase weight he should follow up as an outpatient for weight check and possible uptitration of lasix medications on admission the preadmission medication list is accurate and complete epinephrine epipen mg im once mr1 acetaminophen mg po q8h prn pain mild fever losartan potassium mg po daily magnesium oxide mg po bid gabapentin mg po bid colchicine mg po daily venetoclax mg po daily lidocaine patch ptch td qam hydroxyzine mg po q6h prn anxiety ziprasidone hydrochloride mg po bid metoprolol succinate xl mg po daily docusate sodium mg po bid senna mg po bid prn constipation first line triamcinolone acetonide cream appl tp daily rivaroxaban mg po daily carbamide peroxide drop both ears daily fenofibrate mg po daily atorvastatin mg po qpm furosemide mg po daily acyclovir mg po q8h melatonin mg oral qhs nystatin triamcinolone cream appl tp bid sucralfate gm po bid pantoprazole mg po q24h aspirin mg po daily levothyroxine sodium mcg po daily units breakfast units lunch units dinnermax dose override reason home regimen topiramate topamax mg po daily discharge medications capsaicin appl tp tid prn neuropathy levothyroxine sodium mcg po daily rx levothyroxine euthyrox mcg tablet s by mouth once a day disp tablet refills acetaminophen mg po q8h prn pain mild fever acyclovir mg po q8h aspirin mg po daily atorvastatin mg po qpm carbamide peroxide drop both ears daily colchicine mg po daily docusate sodium mg po bid epinephrine epipen mg im once mr1 fenofibrate mg po daily furosemide mg po daily gabapentin mg po bid hydroxyzine mg po q6h prn anxiety units breakfast units lunch units dinnermax dose override reason home regimen lidocaine patch ptch td qam losartan potassium mg po daily magnesium oxide mg po bid melatonin mg oral qhs metoprolol succinate xl mg po daily nystatin triamcinolone cream appl tp bid pantoprazole mg po q24h rivaroxaban mg po daily senna mg po bid prn constipation first line sucralfate gm po bid topiramate topamax mg po daily triamcinolone acetonide cream appl tp daily venetoclax mg po daily ziprasidone hydrochloride mg po bid discharge disposition home with service facility discharge diagnosis primary diagnosis neuropathy weakness numbness secondary diagnosis hypoglycemia in the setting of insulin dependent type diabetes insomnia depression chronic lymphocytic leukemia benign paroxysmal positional vertigo hypertension hypothyroidism discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear mr it was a privilege to care for you at why was i in the hospital you noted that your left arm leg and face were paralyzed you also noted that you weren t able to appreciate sensation on the left side of your face and your left arm and leg what happened to me in the hospital you received ct scans and an mri of your brain in other words we took pictures of your head these pictures did not show an acute reason for your weakness and loss of sensation which was reassuring your symptoms resolved over the course of your stay and you worked with our physical therapists to help with the symptoms we gave you a cream to treat the neuropathy you endorsed in your left forearm we gave you more lasix medication to help with the swelling in your lower legs what should i do after i leave the hospital continue to take all your medicines and keep your appointments continue taking your insulin as you were prior to the hospitalization you should check your blood sugar at least times a day your levothyroxine synthroid dose was increased you will need repeat labs in weeks to monitor levels we wish you the sincerely your team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies penicillins nsaids non steroidal anti inflammatory drug erythromycin base cheeses soft cottage cream cheese attending chief complaint epigastric pain major surgical or invasive procedure endoscopy history of present illness mr is a man with cll on venetoclax hx testicular cancer iddm hypertension hyperlipidemia obesity right subcortical stroke in with residual left leg weakness ambulates with a cane sick sinus syndrome status post pacemaker depression with psychotic features presenting with sudden onset of epigastric abdominal pain patient states he ate dinner at 30pm yesterday evening and an hour later at 30pm he began experiencing epigastric pain described pain as sharp and stabbing reported associated nausea but no emesis states pain radiated straight to my back denies any alleviating or exacerbating factors did not try to take any medications and instead called an ambulance to bring him to the hospital stated he had never felt this pain before reportedly had a history of gerd and takes a ppi daily when asked if this pain resembled his reflux symptoms he states it s hard to say as he very rarely has reflux symptoms on this regimen denies any diarrhea constipation obstipation dysuria foul smelling urine hematochezia melena reports last bm the day prior to admission which was normal no history of gallstones in the ed initial vitals ra labs significant for wbc plts hgb na bun glu ast alt t bili ap lipase trop x2 lactate ua with glucose but no signs of infection ekg with sinus tachycardia no acute ischemic changes qtc patient underwent cta abd pelvis which showed prelim no acute intra abdominal process specifically no evidence of mesenteric ischemia patient got iv morphine 4mg x2 maalox foamotidine viscous lidocaine patient admitted to oncology for additional management on arrival to floors patient confirms history as above and states his pain improved after getting iv morphine in the ed now down to a past medical history past oncologic history found to have cll incidentally on labs performed during psych admission followed for several years until when he noted night sweats and progressive fatigue ibrutinib complicated by multiple bleeding events including retinal bleed ibrutinib was held lymph node ibrutinib was restarted c b gi and pericardial bleeding ventoclax initiated past medical history non seminoma testicular gct sp cycles ep chronic lymphocytic leukemia as above sick sinus syndrome s p ppm revo ddd mri compatible cad s p des to mid lad in cerebrovascular accident with residual left weakness diabetes mellitus type ii on insulin paf on xarelto hypertension hyperlipidemia morbid obesity obstructive sleep apnea not on cpap pancreatitis hypothyroidism peripheral neuropathy chronic pain osteoarthritis major depression with psychotic features vs schizoaffective disorder per patient anxiety conversion disorder benign paroxysmal positional vertigo glaucoma s p cholecystectomy s p bilateral shoulder surgery s p gastric bypass surgery social history family history father and mother with cardiovascular disease mother died of unknown malignancy physical exam admission physical exam vitals hr data last updated temp tm bp hr o2 sat o2 delivery ra wt lb kg general sitting in chair comfortably eyes closed intermittently throughout interview nad obese heent clear op without lesions or thrush eyes perrl anicteric neck supple no jvd resp no increased wob no wheezing rhonchi or crackles rrr no murmurs rubs gallops gi obese soft distended tympanic to percussion over epigastrum when asked if palpation over epigastrum causes pain during gentle palpation patient says yes and jumps however when palpating the same region without asking if he s tender patient without pain no rebound or guarding ext rle edema trace pedal edema in lle warm skin dry no obvious rashes neuro alert though closes eyes throughout interview responds in short word answers perrl eomi access poc discharge physical exam vitals hr data last updated temp ra general sitting in chair comfortably pleasant conversant heent clear op without lesions or thrush eyes perrl anicteric neck supple no jvd resp no increased wob no wheezing rhonchi or crackles rrr no murmurs rubs gallops gi obese soft distended non tender to palpation ext rle edema trace pedal edema in lle warm skin dry no obvious rashes neuro aox3 answering questions appropriately access poc pertinent results admission labs 23pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 23pm blood neuts monos eos baso absneut abslymp absmono abseos absbaso 48am blood ptt 23pm blood glucose urean creat na k cl hco3 angap 23pm blood alt ast alkphos totbili 23pm blood albumin uricacd 23pm blood lipase 23pm blood ctropnt 33pm urine blood neg nitrite neg protein neg glucose ketone neg bilirub neg urobiln neg ph leuks neg relevant interval labs 21am blood glucose urean creat na k cl hco3 angap 32am blood alt ast ld alkphos amylase totbili 32am blood calcium phos mg uricacd 21am blood vitb12 folate 21am blood 25vitd discharge labs 08am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 08am blood neuts monos eos baso absneut abslymp absmono abseos absbaso 51am blood hypochr anisocy poiklo microcy polychr spheroc ovalocy schisto tear dr rbc mor slide revi 08am blood ptt 08am blood glucose urean creat na k cl hco3 angap 08am blood alt ast ld alkphos totbili 08am blood calcium phos mg uricacd imaging cta a p no acute intra abdominal process specifically no evidence of mesenteric ischemia the appendix is not visualized however there are no secondary signs to suggest appendicitis egd normal mucosa of esophagus fistula with mild erythema and food debris esophageal hiatal hernia healing ulcer of proximal jejunum ekg a paced v sensed mod critera for lvh pathology gastric pouch biopsy corpus type mucosa within normal limits brief hospital course brief hospital course mr is a gentleman w history of cll on venetoclax depression with psychotic features gerd single remote episode of pancreatitis iddm cad s p pci roux en y gastric bypass cholecystectomy hypothyroidism who presented with acute onset severe epigastric pain cta a p lab work cardiac workup were all unrevealing mr was evaluated by gi and underwent egd which revealed a healing jejunal ulcer as well as a fistula his home ppi was made bid and mr was provided with low dose oxycodone prn for pain management course was complicated by periods of lethargy and delirium his levothyroxine was titrated up as his recent tsh was elevated and concern this was contributing to his lethargy mr was also seen by psychiatry who assisted in medication adjustments over the course of his hospitalization mr mental status waxed and waned likely due to his underlying medical issues and medication titration however at discharge his mental status was back to baseline and clear course was further complicated by that was deemed contrast induced nephropathy mr was seen by renal and upon discharge his cr was mr was followed by throughout his hospitalization for assistance in managing his iddm transitional issues please continue to follow mr for his iddm pcp please check a repeat tsh on and titrate his levothyroxine dose accordingly he is being discharged on levothyroxine 125mcg daily gi please follow up with mr after he completes weeks of bid ppi therapy to ensure resolution of epigastric abdominal pain at that point in time please continue him on daily ppi psychiatry please continue to titrate mr medications bariatric surgery please follow up with mr regarding the fistula that was found on egd other issues discharge hemoglobin discharge cr discharge weight 78lbs code full presumed contact son is his primary proxy wife separated is his alternate active problems contrast induced nephropathy mr with seen by renal and deemed likely contrast induced nephropathy we held his colchicine losartan and furosemide we renally dosed his medications however these were resumed on discharge as his renal function recovered cr on discharge of epigastric abd pain jejunal ulcer suspect abd pain healing jejunal ulcer seen on egd cta a p with no concerning findings at this time for infectious ischemic or pancreatic etiologies ecg trop unremarkable for acs initiated on bid ppi for ontinued home mag ox sucralfate provided low dose oxycodone intermittently for pain relief he should follow up with gi as an outpatient lethargy ama request unclear etiology but possibly polypharmacy vs other tme vs hypothyroidism vs delirium waxing waning disorientation most c f superimposed delirium tsh persistently elevated therefore possible that poorly managed hypothyroidism contributing seen by psychiatry who recommended stopping ziprasidone amitriptyline decreasing his gabapentin agreed to discharge with home insulin dependent type diabetes complicated by peripheral neuropathy a1c in home insulin regimen is units times daily followed by held metformin while inpatient will be discharged on regimen of insulin units at breakfast units at lunch and units at dinner resume metformin at home hx roux en y fistula fistula seen by egd bariatric surgery favor no surgical intervention at current time gi also favors deferring egd clipping as unlikely contributing to current presentation vitamin studies wnl added thiamine supplementation ti follow up with dr after discharge elevated lfts mild elevations has had intermittently elevated lfts in past likely drug induced liver injury but unclear precipitant these resolved upon discharge normocytic anemia thrombocytopenia appears stable recent fe studies indicate possibly r t hx gastric bypass vs colon cancer last c scope w tubular adenoma serrated adenoma gi at that time rec f up screen w stool based testing d t difficulty w gi prep ti colon cancer screening hx depression w psychotic features seen by psychiatry d c ziprasidone amitriptyline per above continued escitalopram risperidone and topirimate decreased dose of gabapentin hypothyroidism recent tsh elevated at ft4 low at unclear dose of levothyroxine at home but increased to 125mcg per day per recs ti repeat tsh 6weeks hyperuricemia hx of gout held home colchicine in s o renal injury initiated allopurinol daily home meds were resumed at time of discharge chronic issues swelling per pt at baseline held furosemide in s o renal injury cll stable patient continued on home venetoclax acyclovir ppx chronic back pain stable continued lidocaine patches skin care hx xerosis possibly hypothyroid nystatin triamcinolone creams cad s p pci cva w residual left sided weakness htn ecg trops w o e o acs continued asa atorvastatin metop succ held home losartan renal injury resumed upon discharge hld hypertriglyceridemia cholesterol hdl ldl continued home atorvastatin fenofibrate paf rate controlled metop suc on oac rivaroxaban hx gout nothing acute held home colchicine renal injury started renally dosed allopurinol d c planning min medications on admission the preadmission medication list is accurate and complete acyclovir mg po q8h atorvastatin mg po qpm fenofibrate mg po daily furosemide mg po daily gabapentin mg po bid levothyroxine sodium mcg po daily lidocaine patch ptch td qam losartan potassium mg po daily pantoprazole mg po q24h rivaroxaban mg po daily senna mg po bid prn constipation first line sucralfate gm po bid topiramate topamax mg po daily triamcinolone acetonide cream appl tp daily carbamide peroxide drop both ears daily epinephrine epipen mg im once mr1 hydroxyzine mg po q6h prn anxiety magnesium oxide mg po bid melatonin mg oral qhs metoprolol succinate xl mg po daily nystatin triamcinolone cream appl tp bid venetoclax mg po daily docusate sodium mg po bid acetaminophen mg po q8h prn pain mild fever aspirin mg po daily colchicine mg po daily amitriptyline mg po qhs escitalopram oxalate mg po daily metformin xr glucophage xr mg po daily units breakfast units lunch units bedtimemax dose override reason as per risperidone mg po daily oxycodone immediate release mg po q4h prn pain moderate discharge medications allopurinol mg po daily rx allopurinol mg tablet s by mouth once a day disp tablet refills gabapentin mg po tid rx gabapentin mg capsule s by mouth three times a day disp capsule refills units breakfast units lunch units dinner insulin sc sliding scale using hum insulinmax dose override reason home regimen levothyroxine sodium mcg po daily rx levothyroxine euthyrox mcg tablet s by mouth once a day disp tablet refills lidocaine patch ptch td qpm oxycodone immediate release mg po q6h prn pain moderate pantoprazole mg po q12h rx pantoprazole mg tablet s by mouth twice a day disp tablet refills risperidone mg po qhs rivaroxaban mg po dinner acetaminophen mg po q8h prn pain mild fever acyclovir mg po q8h aspirin mg po daily atorvastatin mg po qpm carbamide peroxide drop both ears daily colchicine mg po daily docusate sodium mg po bid epinephrine epipen mg im once mr1 escitalopram oxalate mg po daily fenofibrate mg po daily furosemide mg po daily hydroxyzine mg po q6h prn anxiety losartan potassium mg po daily magnesium oxide mg po bid melatonin mg oral qhs metformin xr glucophage xr mg po daily do not crush metoprolol succinate xl mg po daily nystatin triamcinolone cream appl tp bid senna mg po bid prn constipation first line sucralfate gm po bid topiramate topamax mg po daily triamcinolone acetonide cream appl tp daily venetoclax mg po daily discharge disposition home with service facility discharge diagnosis primary jejunal ulcer secondary fistula lethargy hypothyroidism insulin dependent diabetes mellitus delirium contrast induced nephropathy depression with psychotic features in remission hyperuricemia elevated lfts discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear it was a pleasure taking part in your care here at why was i admitted to the hospital you were admitted for abdominal pain what was done for me while i was in the hospital we took pictures of your abdomen to determine what was causing your abdominal pain we used a camera to look into your stomach endoscopy and saw a healing ulcer in your small intestine we gave you pain medications anti acid medications to treat the ulcer we had diabetes doctors help manage your blood sugars we had psychiatrists see you to help manage your medications we had the kidney doctors because your kidney levels were high what should i do when i leave the hospital please note that your acid reducing medication pantoprazole should be taken twice a day for the next weeks please check your blood sugars before meals and at bedtime everyday and bring a log of your readings to your next doctors take all of your medications as prescribed follow up with all of your physicians as directed sincerely your care team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies penicillins nsaids non steroidal anti inflammatory drug erythromycin base cheeses soft cottage cream cheese attending chief complaint abdominal major surgical or invasive procedure none history of present illness pmh cll on venetoclax depression with psychotic features t2dm cva presented from osh with malaise abdominal pain left leg pain found to have uti hypotension admitted to oncology ward for further care on arrival to medical ward patient was lethargic but arousable to voice and clearly oriented however he had difficulty staying awake during the interview as he had received 1mg of iv dilaudid in ed several hours prior he noted that he did not feel lethargic prior to receiving iv dilaudid as a result of his sedation a full history and paml could not be obtained he was able to state that he initially presented to osh with malaise lower abdominal pain which he felt radiated to his left leg that was a w difficulty urinating he denied fever chills cough sore throat nausea vomiting diarrhea constipation noted that he had decreased appetite intake at home noted that since foley was placed his abdominal and leg pain is resolved reported that he was tired but asymptomatic on admission to oncology ward per review of outside hospital records patient had elevated cr of and bp to mid during stay he was given ivf and blood pressure rebounded and stayed normal thereafter bladder scan revealed 500cc so foley was placed and ua was not consistent with infection lower extremity duplex performed on both legs and was negative for dvt cth performed for questions of altered mental status and was without acute intracranial pathology given that he gets his care at wife requested transfer in our ed initial vitals ra wbc hgb plt bnp alt ast ca mg phos wnl hco3 bun cr lactate ua with wbc rbc mod bact lg leuk mod bld urine na was osm past medical history past oncologic history found to have cll incidentally on labs performed during psych admission followed for several years until when he noted night sweats and progressive fatigue ibrutinib complicated by multiple bleeding events including retinal bleed ibrutinib was held lymph node ibrutinib was restarted c b gi and pericardial bleeding ventoclax initiated past medical history non seminoma testicular gct sp cycles ep chronic lymphocytic leukemia as above sick sinus syndrome s p ppm revo ddd mri compatible cad s p des to mid lad in cerebrovascular accident with residual left weakness diabetes mellitus type ii on insulin paf on xarelto hypertension hyperlipidemia morbid obesity obstructive sleep apnea not on cpap pancreatitis hypothyroidism peripheral neuropathy chronic pain osteoarthritis major depression with psychotic features vs schizoaffective disorder per patient anxiety conversion disorder benign paroxysmal positional vertigo glaucoma s p cholecystectomy s p bilateral shoulder surgery s p gastric bypass surgery social history family history father and mother with cardiovascular disease mother died of unknown malignancy physical exam admission physical exam vitals temp po bp hr rr o2 sat o2 delivery ra general laying in bed appears calm comfortable lethargic opens eyes to voice then quickly falls back asleep eyes right eye dilated chronically s p cataract surgery per patient anicteric heent op clear but dry mm neck supple normal rom lungs cta anteriorly as is too lethargic to sit forward cv rrr no m r g normal distal perfusion abd soft protruberant no tenderness elicited no guarding genitourinary foley with dark yellow urine significant amount of brown sediment ext warm no deformity no e o trauma of left leg no asymmetry no tenderness to palpation skin warm dry no rash neuro aox3 name year trump nurses name quickly falls asleep but awakens to voice access port in right chest dressing c d i discharge physical exam vss general sitting in chair with eyes closed appears comfortable eyes right eye dilated chronically s p cataract surgery per patient anicteric heent op clear dry mm neck supple normal rom lungs cta b l no increased wob cv rrr no m r g normal distal perfusion abd soft very protuberant tenderness on palpation of lower quadrants bilaterally no rebound tenderness or guarding genitourinary no foley since ext warm no deformity or evidence trauma of left leg no asymmetry or tenderness to palpation skin warm dry no rash neuro aox3 psych irritable with ros prolonged latency of speech not frankly psychotic access poc w no bleeding erythema or discharge pertinent results admission labs 30pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30pm blood neuts monos eos baso atyps absneut abslymp absmono abseos absbaso 03am blood ptt 30pm blood glucose urean creat na k cl hco3 angap 30pm blood alt ast alkphos totbili 30pm blood albumin calcium phos mg 43pm blood lactate 48pm blood lactate discharge labs 35am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 35am blood neuts lymphs monos eos baso metas absneut abslymp absmono abseos absbaso 35am blood glucose urean creat na k cl hco3 angap 35am blood alt ast ld ldh alkphos totbili 35am blood albumin calcium phos mg year old male with cll on venetoclax with pmh significant for depression with psychotic features t2dm cva who presented from osh with malaise abdominal pain left leg pain found to have presumed uti and hypotension acute conditions acute abdominal pain improved presumed complicated uti urinary retention resolved resolved hematuria patient with suprapubic tenderness at osh occurred in setting of acute urinary retention which corresponds to location of lower abdominal pain significant improvement after foley placement however noted worsening of abdominal pain on which prompted further imaging with ct a p alternate cause could be due to recent jejunal ulcer vs known gastric fistula causing intra abdominal complication that was diagnosed via ct scan and egd last admission on less likely as abdomen is benign currently urinalysis grossly positive from therefore initiated ceftriaxone however culture negative given ua results on admission presenting symptoms and high risk for infection in s o cll and treatment decision was made to continue a course of ceftriaxone but extended to a s would be a complicated uti ct a p does not show an acute intra abdominal process but noted gastrogastric fistula or bypass reversal not new and unlikely to cause his pain also consider role of constipation as possible cause of abdominal discomfort and retention lactate unremarkable at renal u s negative completed ceftriaxone x7d d1 constipation relief after bm gi prophylaxis protonix and carafate will schedule outpatient urology appointment to further work up hematuria and cause of urinary retention lle pain most likely neuropathy or referred pain acute urinary retention u s at osh did not show dvt no tenderness or deformity to warrant x ray or cross sectional imaging restarted home gabapentin 100mg tid on with improvement following plan to resume services at discharge constipation currently resolved rec continuing bowel regimen on discharge chronic resolved stable conditions lethargy resolved likely over medication with dilaudid in ed on admission cth at osh negative for acute ich over sedation psych medications also possible but less likely as presented with normal alertness while on home meds versus uti fsg wnl on admission resumed home psychiatry medications that was originally held due to sedation including topomax hydroxyzine and risperidone monitor for reoccurrence hypotension resolved likely hypovolemia as appears dry on exam anti htn meds diuretics likely contributing factors ivf prn hold losartan and lasix as above trend bps restart metoprolol if becomes hypertensive likely hypovolemia related as improved cr with fluids renally dose medications holding lasix losartan foley discontinued and no issues voiding since u s negative for hydronephrosis cll patient had recurrence of night sweats and noted to have an increase in his white blood cell count with prominent lymphocytosis consistent with relapsing disease given these changes he was started on ibrutinib however given multiple significant bleeding events gi bleeding and pericardial bleed further ibrutinib therapy was deferred and venetoclax was initiated in the setting of active infection concern venetoclax was held but now restarted on per primary oncologist continue venetoclax 400mg daily continue acyclovir for infectious prophylaxis transaminitis hld stable uptrending as of alt previously on and ast previously on present on prior admits thought to be drug induced liver injury of low level though unclear causative agent as is on so many agents which could potentially lead to transaminitis hep serologies in were negative given strong indication for current medications will continue except for fenofibrate statin trend lfts daily t2dm continues on with ss per recommendations from last admission held metformin on admission when not eating give sliding scale only trend fsg consider re consulting if trend worsens anemia noted on last hospitalization to be due to iron deficiency and likely contribution from cll venetoclax continue cbc daily maintain type and screen transfuse hgb thrombocytopenia stable likely treatment vs disease trend daily transfuse for plt maintain type and screen history of depression with psychotic features on last hospitalization had fluctuating mental state was followed by psychiatry who adjusted his medications by stopping ziprasidone amitriptyline decreasing gabapentin and continuing escitalopram risperidone and topirimate continue psychiatric medications resumed sedating medications as above ex risperdal melatonin hydroxyzine topamax trend mental status closely re consult psych as needed sss status post ppm atrial paced per ekg in ed continue rivaroxaban 20mg daily hold metoprolol in s o hypotension as above restart prn history of gout holding colchicine in s o renal injury continues on allopurinol daily hypothyroidism dose was adjusted on most recent admission he continues on synthroid daily next re check history of jejunal ulcer continues sucralfate pantoprazole history of cva had right sided subcortical lacunar infarcts in with residual mild left sided weakness but does not have an effect on mobility continues on asa core measures fen ivf replete electrolytes regular diet prophylaxis dvt rivaroxaban as above access port hcp relationship son phone number code full presumed disposition home with services medications on admission the preadmission medication list is accurate and complete acetaminophen mg po q8h prn pain mild fever acyclovir mg po q8h aspirin mg po daily atorvastatin mg po qpm docusate sodium mg po bid escitalopram oxalate mg po daily fenofibrate mg po daily gabapentin mg po tid levothyroxine sodium mcg po daily lidocaine patch ptch td qpm magnesium oxide mg po bid metoprolol succinate xl mg po daily nystatin triamcinolone cream appl tp bid pantoprazole mg po q12h risperidone mg po qhs rivaroxaban mg po dinner topiramate topamax mg po daily triamcinolone acetonide cream appl tp daily venetoclax mg po daily allopurinol mg po daily carbamide peroxide drop both ears daily colchicine mg po daily epinephrine epipen mg im once mr1 furosemide mg po daily melatonin mg oral qhs metformin xr glucophage xr mg po daily losartan potassium mg po daily hydroxyzine mg po q6h prn anxiety sucralfate gm po bid senna mg po bid prn constipation first line oxycodone immediate release mg po q6h prn pain moderate units breakfast units lunch units dinner insulin sc sliding scale using hum insulin discharge medications polyethylene glycol g po daily prn constipation first line units breakfast units lunch units dinner insulin sc sliding scale using hum insulin senna mg po bid acetaminophen mg po q8h prn pain mild fever acyclovir mg po q8h allopurinol mg po daily aspirin mg po daily atorvastatin mg po qpm docusate sodium mg po bid epinephrine epipen mg im once mr1 escitalopram oxalate mg po daily fenofibrate mg po daily gabapentin mg po tid hydroxyzine mg po q6h prn anxiety levothyroxine sodium mcg po daily lidocaine patch ptch td qpm magnesium oxide mg po bid melatonin mg oral qhs metformin xr glucophage xr mg po daily metoprolol succinate xl mg po daily oxycodone immediate release mg po q6h prn pain moderate pantoprazole mg po q12h risperidone mg po qhs rivaroxaban mg po dinner sucralfate gm po bid topiramate topamax mg po daily venetoclax mg po daily held colchicine mg po daily this medication was held do not restart colchicine until outpatient team tells you to restart held furosemide mg po daily this medication was held do not restart furosemide until outpatient team tells you to do so held losartan potassium mg po daily this medication was held do not restart losartan potassium until outpatient team tells you to do so discharge disposition home with service facility discharge diagnosis primary diagnoses uti cll constipation acute abdominal pain secondary diagnoses jejunal ulcer gastro gastric fistula lethargy hypothyroidism delirium insulin dependent diabetes mellitus depression with psychotic features in remission 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 abdominal pain urinary retention and acute kidney injury what was done for me while i was in the hospital we gave you antibiotics for your urinary tract infection we gave you pain medications as needed what should i do when i leave the hospital please check your blood sugars before meals and at bedtime everyday and bring a log of your readings to your next doctors take all of your medications as prescribed follow up with all of your physicians as directed sincerely your care team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies penicillins nsaids non steroidal anti inflammatory drug erythromycin base cheeses soft cottage cream cheese attending major surgical or invasive procedure none attach pertinent results admission labs 30am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30am blood neuts monos eos baso absneut abslymp absmono abseos absbaso 30am blood glucose urean creat na k cl hco3 angap 45am blood alt ast alkphos totbili 04am blood lactate 49am blood lactate 02pm urine color yellow appear clear sp 02pm urine blood neg nitrite neg protein neg glucose ketone neg bilirub neg urobiln neg ph leuks neg urine culture final no growth imaging ct abd pelvis with co lower chest icd leads were demonstrated within the right ventricle and atrium moderate calcification of the coronary arteries the visualized lung fields are within normal limits there is no evidence of pleural or pericardial effusion hepatobiliary normal attenuation of the liver there is no evidence of focal lesions there is no evidence of intrahepatic biliary dilatation the common hepatic duct measures up to mm which is likely secondary to post cholecystectomy changes the gallbladder is surgically absent pancreas the pancreas is atrophic and fatty replaced 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 solid renal lesions or hydronephrosis there is no perinephric abnormality gastrointestinal small hiatal hernia the stomach is unremarkable a surgical clip is adjacent lesser curvature of the stomach possibly secondary a dropped clip during prior cholecystectomy small bowel loops demonstrate normal caliber wall thickness and enhancement throughout diverticulosis of the sigmoid colon is noted without evidence of wall thickening or fat stranding 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 prostate and seminal vesicles are grossly 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 bones there is no evidence of worrisome osseous lesions or acute fracture moderate multilevel degenerative changes of the lower thoracic and lumbar spine included vertebral disc space narrowing osteophytosis and vacuum phenomena soft tissues the abdominal and pelvic wall is within normal limits impression no finding to explain the patient s symptoms discharge labs 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood neuts lymphs monos eos baso other absneut abslymp absmono abseos absbaso 00am blood hypochr anisocy poiklo microcy polychr spheroc ovalocy tear dr acantho rbc mor slide revi 00am blood glucose urean creat na k cl hco3 angap 00am blood alt ast ld ldh alkphos totbili 00am blood albumin calcium phos mg brief hospital course patient summary with cll on venetoclax with history of depression with psychotic features t2dm stroke s p gastric bypass and cholecystectomy who presented with lower abdominal pain and difficulty urinating patient was able to void normally with pvrs cc without intervention workup for cause of abdominal pain was unrevealing acute issues acute abdominal pain patient reported severe lower abdominal pain which he stated was similar to his most recent admission during which he was treated for a uti ua however revealed no evidence of infection in addition ct ap was performed which also did not reveal a cause for the patient s pain recent cta revealed no evidence of mesenterich ischemia recent egd revealed a healing duodenal ulcer for which the patient had been placed on bid ppi he stated this pain was unlike his ulcer pain he remained hemodynamically stable and pain was well controlled with his home regimen of oxycodone ppi and carafate prior to discharge urinary retention patient reported suprapubic tenderness and had a temperature of he was initially treated empirically with cefepime ua however had no evidence of infection and antibiotics were stopped in addition the patient was able to void spontaneously and had pvrs mls chronic issues cll patient had recurrence of night sweats and noted to have an increase in his white blood cell count with prominent lymphocytosis consistent with relapsing disease given these changes he was started on ibrutinib however given multiple significant bleeding events gi bleeding and pericardial bleed further ibrutinib therapy was deferred and venetoclax was initiated in the setting of active infection concern venetoclax was held but now restarted on per primary oncologist continued venetoclax 400mg daily continued acyclovir for infectious prophylaxis paroxysmal afib continued home metoprolol and rivaroxaban t2dm continues on with ss per recommendations from previous admission held metformin on admission history of depression with psychotic features continued risperdal melatonin hydroxyzine topamax sss status post ppm atrial paced per ekg in ed continued rivaroxaban 20mg daily continued metoprolol history of gout continued allopurinol daily hypothyroidism continued synthroid history of jejunal ulcer continued sucralfate and pantoprazole history of cva had right sided subcortical lacunar infarcts in with residual mild left sided weakness but does not have an effect on mobility continued asa this patient was prescribed or continued on an opioid pain medication at the time of discharge please see the attached medication list for details as part of our safe opioid prescribing process all patients are provided with an opioid risks and treatment resource education sheet and encouraged to discuss this therapy with their outpatient providers to determine if opioid pain medication is still indicated medications on admission the preadmission medication list is accurate and complete acetaminophen mg po q8h prn pain mild fever acyclovir mg po q8h allopurinol mg po daily aspirin mg po daily docusate sodium mg po bid escitalopram oxalate mg po daily gabapentin mg po tid levothyroxine sodium mcg po daily lidocaine patch ptch td qpm oxycodone immediate release mg po q6h prn pain moderate pantoprazole mg po q12h rivaroxaban mg po dinner senna mg po bid sucralfate gm po bid atorvastatin mg po qpm fenofibrate mg po daily hydroxyzine mg po q6h prn anxiety magnesium oxide mg po bid melatonin mg oral qhs metformin xr glucophage xr mg po daily risperidone mg po qhs topiramate topamax mg po daily venetoclax mg po daily polyethylene glycol g po daily prn constipation first line metoprolol succinate xl mg po daily discharge medications units breakfast units lunch units dinner insulin sc sliding scale using hum insulin acetaminophen mg po q8h prn pain mild fever acyclovir mg po q8h allopurinol mg po daily aspirin mg po daily atorvastatin mg po qpm docusate sodium mg po bid escitalopram oxalate mg po daily fenofibrate mg po daily gabapentin mg po tid hydroxyzine mg po q6h prn anxiety levothyroxine sodium mcg po daily lidocaine patch ptch td qpm magnesium oxide mg po bid melatonin mg oral qhs metformin xr glucophage xr mg po daily do not crush metoprolol succinate xl mg po daily oxycodone immediate release mg po q6h prn pain moderate pantoprazole mg po q12h polyethylene glycol g po daily prn constipation first line risperidone mg po qhs rivaroxaban mg po dinner senna mg po bid sucralfate gm po bid topiramate topamax mg po daily venetoclax mg po daily discharge disposition home with service facility discharge diagnosis primary diagnosis acute abdominal pain secondary diagnoses cll hypothyroidism insulin dependent diabetes mellitus depression with psychotic features in remission discharge condition mental status clear and coherent level of consciousness alert and interactive discharge instructions dear mr it was a privilege taking care of you at why was i in the hospital you were having abdominal pain and trouble urinating what happened to me in the hospital you had a ct scat of your abdomen which did not reveal any cause for your pain you were able to urinate normally we performed an ultrasound of your bladder which showed that you were able to empty your bladder normally and there was only a small amount of urine left afterwards we performed a lab test on your urine and found that there was no infection there what should i do after i leave the hospital please attend your upcoming appointment with dr on at he will continue to work with you to control your pain if you have another flare in your abdominal pain please call dr attend your urology appointment on at we wish you the best sincerely your team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies sulfa sulfonamide antibiotics penicillins fluconazole strawberry attending chief complaint dyspnea major surgical or invasive procedure none history of present illness ms is a woman with asthma and bronchiectasis who presents with dyspnea cough and weakness admitted for asthma exacerbation patient has been on mass health as her primary insurance over the past years she has lost coverage at the beginning of the year for various reasons and in the setting of being unable to afford and obtain her maintenance medications she has had decomepnsation of her respiratory status she lost her insurance in and between then and sometime in the last weeks when she was able to get it back she has been unable to obtain her long acting inhalers initially breo symbicort she has had a number of er visits to due to respiratory decompensation in addition she has been seen by dr primary care physician and has been started on two courses of steroids and antibiotics in the past month her most recent course was started on with a course of days of levofloxacin and prednisone patient reported progressive dyspnea and weakness over the past few days denies fevers or chills she reports cough productive of clear sputum had musculoskeletal chest pain triggered by cough she denies sick contacts she does have a young grandson who is pre in the home she came to the ed for evaluation in the ed patient s vitals were as follows t98 hr rr bp spo2 on ra cbc without leukocytosis bmp wnl bnp slightly elevated at flu pcr negative she was given duoneb x mg methylpred and cc lr she was admitted to medicine for further work up and management on arrival to the floor patient reports interval improvement with ed interventions less coughing able to complete sentences now past medical history asthma secondary to second hand smoke htn hypercholesterolemia reported in atrius but denied by patient gerd vertigo had one episode one year ago ct was negative improved with meclizine osteoarthritis of knee dermatitis eczematous mitral valve insufficiency social history family history mother maternal grandmother with stroke father and daughter with cancer grandmother with cad pvd physical exam admission physical exam vs temp po bp hr rr o2 sat o2 delivery ra gen nad speaking in hoarse voice but in complete sentences heent ncat neck supple no lad cv rrr no r m g resp diffuse expiratory wheezing with poor air movement abd soft nt nd bs ext no edema skin no rashes neuro alert and oriented x discharge physical exam vs see eflowsheets gen nad speaking in complete sentences heent ncat neck supple no lad cv rrr no r m g resp diffuse expiratory wheezing with good air movement abd soft nt nd bs ext no edema skin no rashes neuro alert and oriented x pertinent results admission labs 40pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 40pm blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 40pm blood glucose urean creat na k cl hco3 angap 26am blood calcium phos mg imaging cxr no acute cardiopulmonary process ct chest very mild bronchiectasis in the right lower lobe residual secretions are noted inside the subsegmental bronchi in the left lower lobe discharge labs 15am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 15am blood glucose urean creat na k cl hco3 angap 15am blood calcium phos mg year old woman with a history of asthma and bronchiectasis who is here with exacerbation of respiratory issues dyspnea presented with acute worsening of dyspnea she has had multiple ed visits recently for the same issue thought to be due to asthma exacerbations on admission cxr was negative for acute abnormalities bnp was normal she was noted to have a diffuse wheeze and was started on a steroid course prednisone 60mg as she had been taking 10mg daily at home as part of a taper she was seen by pulmonology who felt that the diagnosis of asthma was questionable given the lack of obstruction on pfts see pulmonary note from for full details they suspect that she may have vocal cord dysfunction there may also be an element of gerd aspiration and post nasal drip contributing to her symptoms particularly since she reports that her cough is worse at night in addition pulmonary felt that there was a significant component of anxiety contributing to her dyspnea which patient acknowledged may be the case she also carries a diagnosis of bronchiectasis but this was found to be very mild on ct chest she was discharged on a rapid prednisone taper she was continued on home zyrtec montelukast and flonase as well as symbicort omeprazole was increased to bid anca and ige sent per pulmonary recommendations and were pending at time of discharge pulmonary recommended outpatient ent evaluation for vocal cord dysfunction outpatient video swallowing study and repeat outpatient pfts patient reported that she would like to follow up with pulmonary an appointment was pending at time of discharge leukocytosis developed leukocytosis to with no fever or infectious signs likely steroid effect htn continued dyazide and amlodipine gerd continued omeprazole which was increased to bid per pulmonary recommendations minutes spent on discharge coordination and planning transitional issues discharged on rapid prednisone taper omeprazole and flonase increased to bid anca and ige pending at time of discharge pulmonology recommending outpatient ent evaluation for vocal cord dysfunction video swallow and repeat pfts patient reported that she wanted to follow up with pulmonology appointment pending at time of discharge medications on admission the preadmission medication list is accurate and complete aspirin mg po daily vitamin d unit po daily calcium carbonate mg po daily omeprazole mg po daily zyrtec cetirizine mg oral qd montelukast mg po daily albuterol inhaler puff ih q4h prn wheeze dyazide triamterene hydrochlorothiazid mg oral daily ipratropium albuterol neb neb neb q6h prn wheeze amlodipine mg po daily symbicort budesonide formoterol mcg actuation inhalation bid levofloxacin mg po q24h fluticasone propionate nasal spry nu daily discharge medications prednisone mg po daily tapered dose down rx prednisone mg tablet s by mouth once a day disp tablet refills fluticasone propionate nasal spry nu bid rx fluticasone propionate mcg actuation spry nas twice a day disp bottle refills omeprazole mg po bid rx omeprazole mg tablet s by mouth twice a day disp tablet refills albuterol inhaler puff ih q4h prn wheeze amlodipine mg po daily aspirin mg po daily calcium carbonate mg po daily dyazide triamterene hydrochlorothiazid mg oral daily ipratropium albuterol neb neb neb q6h prn wheeze montelukast mg po daily symbicort budesonide formoterol mcg actuation inhalation bid vitamin d unit po daily zyrtec cetirizine mg oral qd discharge disposition home with service facility discharge diagnosis primary dyspnea gerd asthma discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms you came in because your breathing was becoming worse you were seen by the pulmonary doctors who felt that there were several different things contributing to your breathing problems they recommended increasing your omeprazole to twice a day this medication treats acid reflux and acid reflux can sometimes cause breathing issues you will also need to see an ear nose and throat doctor as an outpatient and will need to have a video swallowing study we are sending you home on a prednisone taper take tabs 60mg take tabs 60mg take tabs 60mg take tabs 40mg take tabs mg take tabs 20mg take tabs 20mg take tab 10mg take tab 10mg stop prednisone it was a pleasure taking care of you and we are happy that you re feeling better followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies sulfa sulfonamide antibiotics penicillins fluconazole strawberry attending chief complaint wheezing shortness of breath major surgical or invasive procedure none history of present illness this is an female with a history of asthma chf and hypertension presenting to the emergency department for productive cough of yellow sputum and increased wheezing since the patient also states that night she woke up with chills she has not had another episode of chills the patient is already on a z pak chronically the patient called her pcp and was prescribed steroids on the patient has been taking her inhaler and nebulizers every hours and her pro air times a day the patient states she is still wheezing and coughing the patient states her voice has become raspy the patient has not measured any fevers at home her p o appetite has been okay no chest pain no nausea no vomiting no no history of blood clots no history of dvt no hemoptysis the patient states she is not having any more trouble than normal laying flat she has not noticed increased swelling in her legs initial vs t hr bp rr ra exam respiratory mild respiratory distress no accessory muscle use equal chest rise wheezes in all fields with good air movement throughout cv rrr with s1 and s2 no s3 s4 murmurs heaves thrills rubs appreciated jvd trace peripheral edema radial and pedal pulses bilaterally pertinent labs imaging studies cxr low lung volumes no acute cardiopulmonary abnormality cbc wnl patient received duonebs x3 methylpred mag sulfate on arrival to the floor she confirms the above story no sick contacts at home days of increased wheezing some sob that is now improved but mostly just concerned about the wheezing no fevers or chills a mild headache no abdominal nausea vomiting diarrhea or constipation past medical history asthma hypertension gerd social history family history mother maternal grandmother with stroke father and daughter with cancer grandmother with cad pvd physical exam admission vitals temp po bp hr rr o2 sat o2 delivery ra general alert and oriented x3 no acute distress heent nc at mmm eomi neck supple non tender lungs diffuse wheezing bilaterally good air movement no crackles or consolidations cv rrr no murmurs rubs or gallops gi soft non tender and non distended bs ext warm and well perfused non edematous neuro alert and oriented x3 cnii xii grossly intact no focal neurologic deficit discharge vitals temp tm bp hr rr o2 sat o2 delivery ra general alert and oriented x3 no acute distress heent nc at mmm eomi neck supple non tender lungs diffuse wheezing bilaterally good air movement no crackles or consolidations cv rrr no murmurs rubs or gallops gi soft non tender and non distended bs ext warm and well perfused non edematous neuro alert and oriented x3 cnii xii grossly intact no focal neurologic deficit pertinent results admission 25pm glucose urea n creat sodium potassium chloride total co2 anion gap 25pm estgfr using this 25pm ctropnt probnp 33am voidspec specimen r 33am wbc rbc hgb hct mcv mch mchc rdw rdwsd 33am neuts lymphs monos eos basos im absneut abslymp absmono abseos absbaso 33am plt count discharge 45am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 45am blood glucose urean creat na k cl hco3 angap imaging cxr heart size is top normal the mediastinal and hilar contours are unremarkable apart from minimal tortuosity of the thoracic aorta and mild atherosclerotic calcifications at the aortic knob the pulmonary vasculature is normal lung volumes are low but the lungs are clear no pleural effusion or pneumothorax is seen there are no acute osseous abnormalities impression low lung volumes no acute cardiopulmonary abnormality brief hospital course this is an year old female with past medical history of asthma gerd recently diagnosed fungal laryngitis admitted with acute asthma exacerbation treated with steroids with slow improvement able to be discharged home on prednisone taper with outpatient follow up moderate persistent asthma with acute exacerbation patient with pfts with evidence of asthma but no obstructive disease also undergoing workup with ent with recent laryngoscopy showing fungal laryngitis who presented with several days of increased wheezing cxr reassuring no pneumonia she was treated with iv solumedrol 125mg in the ed and then transitioned to po prednisone 60mg on admission with standing and prn nebulizers as well as her home asthma allergy medications unclear trigger for her symptoms over hours patient slowly improved back to baseline was able to ambulate without symptoms and peakflow returned to baseline she reported baseline as per discussion with outpatient pulmonologist discharged with prednisone taper and planned pcp and ent follow up for ongoing treatment and workup of her recurrent respiratory issues fungal laryngitis recently diagnosed by ent weeks ago unclear how if this may relate to her chronic respiratory symptom burden continued on nystatin with plan for previously scheduled close ent follow up gerd continued home omeprazole and ranitidine htn continued home triamterene hctz amlodipine transitional issues emergency contact code full with limited trial of life sustaining measures minutes spent on discharge medications on admission the preadmission medication list is accurate and complete aspirin mg po daily ipratropium albuterol neb neb neb q6h prn wheeze montelukast mg po daily omeprazole mg po bid zyrtec cetirizine mg oral qd dyazide triamterene hydrochlorothiazid mg oral daily symbicort budesonide formoterol mcg actuation inhalation bid amlodipine mg po daily albuterol inhaler puff ih q4h prn wheeze calcium carbonate mg po daily vitamin d unit po daily fluticasone propionate nasal spry nu bid nystatin oral suspension ml po qid azithromycin mg po 3x week ranitidine mg po bid discharge medications prednisone mg po daily duration doses start today first dose next routine administration time this is dose of tapered doses rx prednisone mg tablet s by mouth once a day disp tablet refills prednisone mg po daily duration doses start after mg daily tapered dose this is dose of tapered doses prednisone mg po daily duration doses start after mg daily tapered dose this is dose of tapered doses albuterol inhaler puff ih q4h prn wheeze amlodipine mg po daily aspirin mg po daily azithromycin mg po 3x week calcium carbonate mg po daily dyazide triamterene hydrochlorothiazid mg oral daily fluticasone propionate nasal spry nu bid ipratropium albuterol neb neb neb q6h prn wheeze montelukast mg po daily nystatin oral suspension ml po qid omeprazole mg po bid ranitidine mg po bid symbicort budesonide formoterol mcg actuation inhalation bid vitamin d unit po daily zyrtec cetirizine mg oral qd discharge disposition home discharge diagnosis primary asthma secondary gastroesophageal reflux disease 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 caring for you at why was i in the hospital you were wheezing and short of breath what happened to me in the hospital you got iv and oral steroids and nebulizer treatments to improve your breathing you felt better and continued to have good oxygen levels without needing extra oxygen so you were discharged home what should i do after i leave the hospital you should complete your prednisone taper and follow up with your pulmonologist and ent doctor regarding ongoing workup surrounding your asthma and cough we wish you the best sincerely your team followup instructions

name unit no admission date discharge date date of birth sex f service orthopaedics allergies magnesium citrate shellfish derived attending chief complaint right knee pain major surgical or invasive procedure right total knee replacement history of present illness healthy female with right knee oa presenting for total knee replacement past medical history congenital hip dysplasia scoliosis ocular migraines social history family history non contributory 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 staples scant serosanguinous drainage thigh full but soft no calf tenderness strength silt nvi distally toes warm pertinent results 25am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 45am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 25am blood plt 45am blood plt 30am blood plt 30am blood glucose urean creat na k cl hco3 angap 30am blood estgfr using this 30am blood 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 on postop day the patient complained of uncontrolled pain a brief course of toradol was added with adequate improvement otherwise pain was controlled with a combination of iv and oral pain medications the patient received lovenox for dvt prophylaxis starting on the morning of pod the patient was unable to void post operatively she had to be straight cath ed x1 the patient was able to void after being straight cath ed x1 the surgical dressing was changed and the silverlon dressing was removed on pod the surgical incision was found to be clean and intact without erythema or abnormal drainage 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 and the wound was benign the patient s weight bearing status is weight bearing as tolerated on the operative extremity please use walker or crutches at all times for weeks ms is discharged to home with services in stable condition medications on admission the preadmission medication list is accurate and complete ibuprofen mg po bid prn pain mild zolpidem tartrate mg po qhs prn insomnia discharge medications acetaminophen mg po q8h rx acetaminophen mg tablet s by mouth every hours disp tablet refills docusate sodium mg po bid rx docusate sodium mg tablet s by mouth twice daily disp tablet refills enoxaparin sodium mg sc daily start first dose first routine administration time rx enoxaparin mg ml mg sc daily disp syringe refills senna mg po bid rx sennosides senna mg tablet by mouth twice daily disp tablet refills tramadol mg po q4h prn pain moderate rx tramadol mg tablet by mouth every hours disp tablet refills zolpidem tartrate mg po qhs prn insomnia held ibuprofen mg po bid prn pain mild this medication was held do not restart ibuprofen until cleared by surgeon to resume nsaids discharge disposition home with service facility discharge diagnosis right knee osteoarthritis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions please 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 shaking chills increasing redness or drainage from the incision site chest pain shortness of breath or any other concerns please follow up with your primary physician regarding this admission and any new medications and refills resume your home medications unless otherwise instructed 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 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 days if you would like your medication mailed to your home you may not drive a car until cleared to do so by your surgeon please call your surgeon s office to schedule or confirm your follow up appointment swelling ice the operative joint 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 please do not take any non steroidal anti inflammatory medications nsaids such as celebrex ibuprofen advil aleve motrin naproxen etc anticoagulation please continue your lovenox for four weeks to help prevent deep vein thrombosis blood clots if you were taking aspirin prior to your surgery it is ok to continue at your previous dose while taking anticoagulation medication stockings x weeks wound care please keep your incision clean and dry it is okay to shower five days after surgery but no tub baths swimming or submerging your incision until after your four week checkup please place a dry sterile dressing on the wound each day if there is drainage otherwise leave it open to air check wound regularly for signs of infection such as redness or thick yellow drainage staples will be removed by at follow up appointment approximately two weeks after surgery once at home home dressing changes as instructed wound checks and staple removal at two weeks after surgery activity weight bearing as tolerated on the operative extremity two crutches or walker at all times for weeks mobilize rom as tolerated no strenuous exercise or heavy lifting until follow up appointment physical therapy weight bearing as tolerated right lower extremity no range of motion restrictions mobilize frequently ambulate with assistive device crutches or walker x weeks treatments frequency wound checks for erythema drainage dry dressing changes as needed staples to be removed at first clinic visit lovenox teaching followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies midazolam latex attending chief complaint right sided chest pain and worsening sob major surgical or invasive procedure chest tube placement history of present illness mr is a y o m with relevant pmh of a fib on coumadin sick sinus syndrome w pacemaker vessel cabg who presents with r sided chest pain and worsening sob in the first week of the patient developed r sided pain over the course of a few days there was intermittent mild non productive cough he describes the right sided chest pain as non radiating sharp and worse when lying down on either side he is able to point to his lateral right side as the focal point of pain after a few days of these symptoms he was seen at on and following cxr indicated r medial lobe consolidation he was then started on day course of azithromycin however the chest pain then persisted he then had a business trip to during which he noticed worsening sob sob was worsened with lying flat he stated that sleeping became a problem d t pain and required sleeping upright though sob was not affected by exertion notably he denied fever chills night sweats and weight changes additionally patient noted that a couple of weeks ago he accidently doubled up on his warfarin one day but he was sure he had not recently doubled up on any dosing on ros he endorsed feeling bloated and have intermittent loose stools but denied diarrhea he has some difficulty initiating urination and notes a weak stream which is not new he denied ha acute vision hearing changes dysphagia facial flushing nausea vomiting dysuria and rashes or other skin changes he denied any travel to tb endemic countries or exposure to prison or homeless populations in the ed initial vital signs were notable for hr bp rr at on ra exam notable for decreased right lower breath sounds distended abdomen but nontender to palpation pitting edema on bilateral lower extremity labs were notable for wbc hgb hct plt ptt inr ma k cl bicarb bun cr glu lactate trop x2 flu a b neg probnp ua color yellow appear clear specgr ph urobil neg bili neg leuk neg bld neg nitr neg prot tr glu neg ket neg rbc wbc bact none yeast none epi studies performed include ecg notable for afib t wave inversion in v2 and borderline lvh repeat ecg unchanged bedside ultrasound of abdomen fast exam does not show any fluid or ascites visualization of right sided pleural effusion chest pa lat large right pleural effusion with significant compressive atelectasis of the right mid and lower lobes please refer to subsequent ct for further details cta chest no pulmonary embolism or acute aortic process large right pleural effusion with significant collapse of the right lung relative hypodense mass seen within the collapsed right lower lobe raises potential concern for malignancy or pneumonia consider thoracentesis with cytology sclerotic focus with the t6 vertebra attention on followup advised patient was given morphine 2mg iv consults none vitals on transfer hr bp rr at on ra upon arrival to the floor patient noted that his pain was better controlled since being given morphine he stated he felt a little bloated which was unchanged otherwise he had no acute changes in his symptoms since presenting to the ed past medical history afib sick sinus syndrome s p pacemaker placement cad s p vessel cabg w graft htn parathyroidectomy for hypercalcemia gland removed social history family history he stated he has family history of heart problems and diabetes though no known history of cancer physical exam admission exam vitals temp po bp l lying hr rr o2 sat o2 delivery ra general alert and interactive lying upright in bed nad pleasant heent ncat perrl eomi sclera anicteric and without injection mmm no cervical lad or masses cardiac irregularly irregular normal s1 s2 no murmurs rubs gallops lungs decreased breath sounds on right side up of his total lung field otherwise no wheezes crackles rhonchi abdomen mild distension bs soft non tender no hsm or masses palpated extremities trace edema bilaterally pulses dp radial bilaterally well healed old surgical scar on r medial lower leg skin warm cap refill 2s no rash some cherry hemangiomas diffuse across body neurologic cn2 intact strength throughout normal sensation gait is normal aox3 discharge exam po ppearing comfortable in nad interactive lying in bed mmm op clear without lesions irregular hr no murmurs appreciated slight decrease in breath sounds at right base otherwise clear lungs abdomen soft nontender nondistended no peripheral edema pulses distally no rashes bandage over chest tube site moving all extremities pertinent results admission labs 33am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 33am blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 33am blood ptt 33am blood glucose urean creat na k cl hco3 angap 33am blood alt ast ld ldh alkphos totbili 33am blood probnp 33am blood ctropnt 20pm blood ctropnt 33am blood albumin calcium phos mg discharge interval labs 10am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood glucose urean creat na k cl hco3 angap 10am blood ptt 00am blood calcium phos mg 00am blood cea psa afp 10am blood ca pnd imaging chest pa lat on admission large right pleural effusion with significant compressive atelectasis of the right mid and lower lobes please refer to subsequent ct for further details cta chest no pulmonary embolism or acute aortic process large right pleural effusion with significant collapse of the right lung relative hypodense mass seen within the collapsed right lower lobe raises potential concern for malignancy or pneumonia consider thoracentesis with cytology sclerotic focus with the t6 vertebra attention on followup advised ct chest w o contrast interval reexpansion of the right lung status post chest tube placement with scattered areas of ground glass opacity in the right lung likely representing reexpansion pulmonary edema a small right pneumothorax which was not visualized on prior chest radiographs and a small residual right pleural effusion areas of residual opacity primarily in the right middle lobe and right lower lobe are favored to represent atelectasis however underlying pneumonia or a small mass cannot be entirely excluded unchanged calcified aneurysm of the splenic artery nonspecific mm hypodensities in the liver which can be further evaluated with mri abdomen with contrast cxr portable interval worsening of large right mid and lower lung opacities likely representing a combination of pleural effusion and atelectasis however a superimposed infectious process or mass cannot be excluded small right apical pneumothorax ct abdomen pelvis with contrast no evidence of primary malignancy or metastatic disease in the abdomen or pelvis cholelithiasis without evidence cholecystitis partially visualized loculated right pleural effusion pleural fluid cytology consistent with metastatic adenocarcinoma brief hospital course mr is a y o m with relevant pmh of a fib on coumadin sick sinus syndrome w pacemaker vessel cabg who presented with r sided chest pain and worsening sob found to have malignant pleural effusion with concern for lung primary acute issues pleural effusion with right lung collapse adenocarcinoma of unknown primary patient previously treated with z pack on with no impact on symptoms cta chest demonstrated large r sided effusion with significant lung collapse and hypodense mass as well as sclerotic features on t6 vertebrae ip placed chest tube w 5l drainage cytology showed adenocarcinoma with immunostaining that was not c w a lung primary ct chest did not clearly demonstrate a large mass ct a p showed no evidence of mass lesion heme onc was consulted and felt this was most likely pulmonary in origin they are working to arrange outpatient in the thoracic clinic for this week hypotension likely hypovolemic in the setting of large volume pleural effusion drainage no fevers or leukocytosis to suggest infection small pneumothorax but no e o tension pneumo improved with 1l lr and holding home lisinopril lisinopril was held at discharge chronic issues afib sick sinus syndrome s p pacemaker placement chads vasc score of he presented w supratherapeutic inr though no indication of bleeding held home warfarin periprocedurally and did not bridge continued home verapamil at discharge mr was started on lovenox given malignancy and likelihood of procedures in the near future for ongoing diagnosis suprathereuptic inr resolved unclear cause of elevated inr be due to recent azithro s p vit k po mg and 1u ffp normalized cad s p vessel cabg w lima graft continued home atorvastatin htn held home lisinopril mg given mild hypotension this admission transitional issues please ensure that patient follows up with thoracic oncology tumor markers sent prior to d c have not resulted at time of discharge please restart lisinopril as indicated please discuss ongoing anticoagulation plan with patient pending further work up of malignancy lovenox vs return to warfarin or doac please repeat creatinine within one week to ensure stability given contrast exposure and initiation of lovenox code full code contact son physician at x minutes spent on discharge planning and care coordination on day of discharge medications on admission the preadmission medication list is accurate and complete verapamil sr mg po q24h warfarin mg po daily16 lisinopril mg po daily atorvastatin mg po qpm finasteride mg po daily aspirin mg po daily discharge medications acetaminophen mg po q8h prn pain mild fever rx acetaminophen mg tablet s by mouth every hours disp tablet refills enoxaparin sodium mg sc bid rx enoxaparin mg ml mg sc twice a day disp syringe refills polyethylene glycol g po daily prn constipation third line rx polyethylene glycol gram powder s by mouth daily disp packet refills tramadol mg po q6h prn pain moderate rx tramadol mg tablet s by mouth every hours disp tablet refills aspirin mg po daily atorvastatin mg po qpm finasteride mg po daily verapamil sr mg po q24h held lisinopril mg po daily this medication was held do not restart lisinopril until told to restart by your pcp home discharge diagnosis malignant pleural effusion adenocarcinoma of possible lung 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 stay at why was i here you were having pain and trouble breathing what was done while i was here you had a chest tube place and fluid drained out the fluid showed cells that are adenocarcinoma you had a ct scan of your chest abdomen and pelvis which did not find a tumor you were seen by oncology who recommended in their clinic for ongoing work up what should i do when i go home you should schedule a follow up appointment with your pcp after discharge medication changes stop warfarin start lovenox start tylenol start miralax start tramadol it was a pleasure taking care of you your care team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies no known allergies adverse drug reactions attending chief complaint llq pain major surgical or invasive procedure flexible sigmoidoscopy history of present illness y o go lady w recent dx of ibd likely on prednisone po presenting to ed w llq pain and bloody diarrhea pt reports waking up this morning at am w mid abdominal pain quickly localizing to llq reports this is the most pain she has ever felt endorsed some dysuria and l flank pain pt had multiple episodes of vomiting in the am that were non bloody and green bilious she also reports episodes of diarrhea mixed w blood which is baseline for her in the setting of internal hemorrhoids and recent ibd dx in terms of her dx pt reports gradual change in bowel movements this past year after seeing multiple providers she eventually had uncomplicated colonoscopy on histology confirmed colitis in the ascending descending colon sigmoid and rectum w normal mucosa in specimens from ti ulcerated nodules no report of granulomata or dysplasia pt received dx of and initiated on mg pred on reporting good compliance since given less than ideal symptom control episodes of diarrhea daily prednisone increased to mg on by outpt gi also started hydrocortisone enema performed x1 on in the ed initial vitals t hr bp rr18 o2sat ra exam notable for no cmt adnexal tenderness diffuse ttp iud strings labs notable for crp urine ucg neg ua bland serum lytes cbc lfts wnl imaging notable for ct abd pelv w con rectosigmoid inflammation suggestive of ibd iud migration to the r mild l hydronephrosis no ureteral stone but study w con sig flex pending pt given 1l ns iv mg morphine iv acetaminophen mg po fleet enema saline sig flex prep pt underwent uncomplicated sig flex per verbal sign out pending full report notable for friable mucosal tissue inflammation extending up to descending colon suggestive of ibd flare pt was evaluated on the floor after return from sig flex she reported severe nausea and llq pain improved only in the setting of pain medication she confirmed the above admission history was informed about upcoming ob gyn exam and pelvic u s as well as about pain medication limitations no opioids nsaids she confirmed full code status and named boyfriend as emergency contact review of systems general no weight loss fevers sweats eyes no vision changes ent no odynophagia dysphagia neck stiffness cardiac no chest pain palpitations orthopnea resp no shortness of breath or cough gi nausea vomiting diarrhea gu dysuria neuro no unilateral weakness numbness headache msk no myalgia or arthralgia heme no bleeding or easy bruising lymph no swollen lymph nodes integumentary no new skin rashes or lesions psych no mood changes past medical history migraines ibd angular cheilitis social history family history reports that grandmother had disease physical exam admission physical exam vitals t po bp r lying hr rr o2sat ra general a ox3 lying in bed in pain w nausea heent sclerae anicteric mmm neck supple jvp not elevated no lad cv rrr normal s1 s2 no murmurs rubs gallops lungs clear to auscultation anteriorly no wheezes rales rhonchi abdomen bowel sounds present x4 diffuse ttp increased in llq no rebound or guarding gu no foley ext warm well perfused pulses no clubbing cyanosis edema skin warm dry no rashes or notable lesions neuro a ox3 moving all extremities w purpose discharge physical exam vitals ra general a ox3 no acute distress resting in bed heent sclerae anicteric mmm neck supple jvp not elevated no lad cv rrr normal s1 s2 no murmurs rubs gallops lungs clear to auscultation bilaterally no wheezes rales rhonchi abdomen bs non ttp no rebound guarding gu no foley ext warm well perfused pulses no clubbing cyanosis edema skin heme crusted ulcer at the r preauricular lymph nodes faintly palpable mobile nontender r inferior precervical ln neuro a ox3 cn2 intact moving all extremities w purpose pertinent results admission labs 17am lactate 11am glucose urea n creat sodium potassium chloride total co2 anion gap 11am estgfr using this 11am alt sgpt ast sgot alk phos tot bili 11am lipase 11am albumin 11am crp 11am wbc rbc hgb hct mcv mch mchc rdw rdwsd 11am neuts monos eos basos im absneut abslymp absmono abseos absbaso 11am plt count 47am urine hours random 47am urine ucg negative 47am urine color straw appear cloudy sp 47am urine blood neg nitrite neg protein neg glucose neg ketone bilirubin neg urobilngn neg ph leuk neg notable labs crp alt ast alk phos tbili hiv ab neg hav ab neg hbsag neg hbsab pos hbcab neg hcv ab neg ppd neg discharge labs na k cl hco3 bun cr wbc hgb hct plt crp micro stool o p no ova and parasites seen moderate rbc s many polymorphonuclear leukocytes ucx no growth fecal culture no salmonella shigella campylobacter vibrio yersinia e coli h7 c diff negative imaging ct abdomen and pelvis w contrast impression hyperemia of the rectosigmoid and mild wall thickening concerning for flare of inflammatory bowel disease an iud is seen extending just beyond the borders of the myometrium in the pelvis to the right of midline bilateral duplicated collecting systems and ureters the inferior moiety of the duplicated renal collecting system demonstrates delayed excretion of contrast and mild hydronephrosis the mid to distal left inferior ureter is not well assessed but no definite ureteral stone is seen other sources of obstruction cannot be excluded correlate with history of vesicoureteral reflux if this has not been previously evaluated recommend outpatient urology periportal edema which can be seen in the setting of aggressive hydration pelvic us findings the uterus is anteverted and measures x x cm the endometrium is homogenous and measures mm as seen on same day ct the iud extends past the borders of the myometrium a small portion of the iud appears to be in the endometrium the ovaries are normal there is a small amount of free fluid impression as seen on same day ct the iud extends past the borders of the myometrium a small portion of the iud appears to be in the endometrial canal small amount of free fluid mr impression mucosal hyperenhancement of the distal sigmoid colon and rectum with surrounding inflammatory changes in the mesorectal fat and reactive lymph nodes the findings are compatible with proctocolitis for which inflammatory bowel disease is a consideration given the clinical history mr w and w o contrast impression no evidence of perianal fistula sinus tract or abscess again seen is mucosal hyperenhancement of the distal sigmoid colon and rectum with surrounding inflammatory changes in the mesorectal fat and reactive lymph nodes again seen is a malpositioned intrauterine device likely perforating the uterus as previously reported path gi mucosal biopsies on flex sigmoidoscopy pathologic diagnosis a sigmoid colon active colitis moderate see note a rectum active colitis moderate see note note granulomas or dysplasia not identified stains for cmv are negative control satisfactory brief hospital course g0 with recently diagnosed ibd believed to be poorly controlled on po prednisone who presented with llq pain and bloody diarrhea with ct and flex sig consistent with ibd flare with negative infectious work up currently on iv solumedrol c b rash c f vzv reactivation discharged on initiation of infliximab for improved ibd control brief hospital course by problem below active issues ibd flare ibd confirmed on cls with biopsy began pred 40mg qd on uptitrated to pred 60mg qd on with hydrocortisone enema i the setting of persistent disease presented to in setting of continued disease activity on with severe llq pain bloody diarrhea and non bloody emesis imaging mre ct abd pelvis endoscopy consistent with moderate to severe flare with no evidence of perianal infection abscess fistula low suspicion for colonic perf s p colonoscopy no free air pregnancy negative test in ed pid given no cmt on ed exam or sxs or trauma c diff and stool cx negative crp downtrended appropriately over hospitalization gi was consulted for treatment recommendations for pain pt was treated with iv tylenol to mild effect nsaids and opioids were contraindicated iso ibd flare for her ibd pt was treated with iv solumedrol 20mg she was also started on infliximab on after negative ppd negative hepatitis a b c serologies and s p 24h valacyclovir treatment for presumptive vzv reactivation patient was tolerating a low residue diet with no pain on discharge denying loose bowel movement crp peaked at on crp on discharge discharge on po prednisone 40mg with plan to taper by patient s gi second infliximab infusion on hyperkalemia on the patient was found to have a k of on routine am labs however on re check without fluids or other intervention and requesting no tourniquet the patient s k normalized suggesting pseudohyperkalemia notably had a normal ekg and denied weakness palpitations lightheadedness on the patient had a k of again felt likely to be secondary to pseudohyperkalemia the patient has been counseled regarding this finding and of clinical signs for which she should seek medical attention will suggest re check at outpatient provider with close mild elevated transaminasemia elevated alt to and ast to on screening labs mild elevation felt potentially secondary to initiation of valacyclovir for vzv reactivation downtrending on am labs today will request recheck on close iud malposition during ct ap w contrast the patient was found to have incidental finding of malpositioned iud with myometrial invasion ob gyn was consulted who recommended pelvic ultrasound which was consistent per ob gyn no need for emergent removal and the patient was scheduled for outpatient on at 45am chief resident clinic at hydronephrosis on abdominal pelvic ct with contrast incidental hydronephrosis was found per discussion with radiology did not appear consistent with obstructive uropathy secondary to nephrolithiasis no urinary complaints during hospitalization with normal renal function and bland ua have passed a stone but no residual evidence cr remained stable over hospitalization patient advised to seek medical care and or ultrasound if develops urinary symptoms flank pain or nausea or if hydronephrosis persists pain control during admission opioids and nsaids were avoided pain adequately controlled on iv po acetaminophen transitional issues pt has an iud which has invaded into the myometrium of her uterus and should be removed an outpatient appointment with ob gyn has been scheduled on at 45am chief resident clinic at pt has mild l sided hydronephrosis found on ct scan which radiology feels is not related to a renal stone causing obstruction other causes of obstruction are possible pt should have ultrasound in future to re evaluate and further workup should be considered if hydronephrosis is persistently present continue po prednisone 40mg until second infliximab infusion on for which patient will receive instructions from gi primary consider dexa scan for ankylosing spondylitis eval as an outpatient and prior to starting biologics patient found to be hav ab negative please consider hav vaccination patient with likely pseudohyperkalemia with am labs of which normalized on re check please check k on during gi with dr patient with incidental elevated transaminasemia likely in the setting of valacyclovir initiation downtrending on discharge please check lfts on during gi with dr medications on admission the preadmission medication list is accurate and complete prednisone mg po daily hydrocortisone acetate foam appl pr tid discharge medications prednisone mg po hydrocortisone acetate foam appl pr tid infliximab infusion valacyclovir 1000mg tid until discharge disposition home discharge diagnosis primary ibd flare vzv reactivation iud malposition hydronephrosis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms why were you admitted you were admitted for increased abdominal pains and bloody stool what was done for you while you were in the hospital we consulted our gi service who recommended a plan for your treatment which you received we performed a lower gi endoscopy which showed active inflammatory bowel disease ibd and was negative for other acute causes of your abdominal pain we performed tests that showed no evidence of infection we screened you for tuberculosis and hepatitis a b and c all of which were negative prior to beginning a new medication called infliximab we gave you iv steroids which eventually helped but introduced infliximab to achieve better control of your ibd we imaged your abdomen and pelvis which incidentally showed that your iud was incorrectly positioned we asked our ob gyn service to see you for the iud who felt there was no need to remove it emergently they arranged an appointment for you to have your iud removed as an outpatient as below we found that you had elevated potassium levels which we believe was due to the way in which your blood was drawn when we re checked it it was normal we found a small increase in your liver enzymes that began to normalize this may be secondary to your new medication of which you have more days we will ask your gi doctor to re check what should you do when you leave the hospital please take all of your medications and go to your follow up appointments as described in this discharge summary if you experience any of the danger signs listed below please call your primary care physician or come to the emergency department immediately it was a pleasure caring for you here at best wishes your care team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies amlodipine lisinopril ibuprofen gabapentin naproxen flanax naproxen attending chief complaint shortness of breath major surgical or invasive procedure none history of present illness ms is a female with history of poorly controlled htn gerd and former pack year history of smoking who presents with ongoing symptoms of dyspnea and cough for the past days history is obtained with the help of an in person interpreter patient first developed symptoms of dyspnea and worsening cough on she went to urgent care on where she says they performed an extensive workup including cxr flu swab ct scan nasopharyngeal endoscopy as well as possibly egd she was told initially that her throat was inflamed but when they looked with a camera they found no evidence of airway obstruction or any abnormalities she also says she was told her esophagus was inflamed her breathing started to improve with breathing treatments and they wanted to keep observing her that evening but she preferred to be discharged ama she was discharged with a course of levaquin she notes she has an inhaler that she uses rarely which was prescribed by her pcp while ago for doe but nothing as severe as her current symptoms she felt like she was dying because it was so hard to breathe she also notes that she was coughing and bringing phlegm up before but now her phlegm seems to be stuck in her lungs and she s unable to bring it up she notes pain in her chest and abdominal muscles when she coughs she has never had pfts done or seen a pulmonologist she wasn t aware of an asthma or copd diagnosis she smoked1ppd from the age of to the age of she quit smoking cold years ago and hasn t smoked since she has had uncontrolled hypertension for which her pcp had to refer her to a cardiologist she notes that her hydralazine was increased from 10mg to 25mg tid as of per refill history looking back through chart there s a phone note indicating that she was previously on cloinidine tid but had side effects with this and went back down to tid she had leg swelling with amlodipine and cough with lisinopril in the ed vs on arrival ra peak flow pre peak flow post this morning ra ecg w o ischemic changes pe aaox3 expiratory wheezes diffusely good air movement legs w o c c e labs flu negative imaging cxr reported as clear but per formal repeat cannot officially rule out lingular opacity recommending 2vcxr if clinically indicated impression admit for copd exacerbation steroids azithro interventions duonebs iv solumedrol 80mg 500mg azithromycin home meds including home antihypertensives course on arrival to ed she was triggered for tachypnea with respiratory rate of initially requiring q2 nebs but spaced out prior to transfer to floor with rr past medical history depression hypertension fatty liver vitamin d deficiency chronic obstructive pulmonary disease anxiety social history family history reviewed and found to be not relevant to this illness reason for hospitalization physical exam admission exam vs temp po bp hr rr o2 sat o2 delivery ra dyspnea rass pain score gen nad eyes perrla anicteric ent mmm heart rrr no r m g lungs expiratory wheezes throughout with moderately restricted air movement subjective dyspnea without tachypnea abd soft ntnd ext no pedal edema skin no obvious skin breakdown or rashes vasc wwp neuro a ox4 no focal sensorimotordeficits psych pleasant calm cooperative discharge exam general alert and in no apparent distress eyes anicteric pupils equally round no conjunctival injection or other erythema ent ears and nose without visible erythema masses or trauma mild erythema of oropharynx mmms cv rrr no m r g resp ctab improved gi abdomen soft non distended non tender to palpation bowel sounds present gu no suprapubic tenderness msk no erythema or swelling of joints skin no rashes or ulcerations noted extr wwp no edema neuro alert interactive face symmetric gaze conjugate with eomi speech fluent motor function grossly intact symmetric psych pleasant appropriate affect pertinent results pertinent results wbc hgb plts 200s bun cre alt ast urine cx neg blood cx ngtd cxr no consolidations heart size is normal there is no pleural effusion no pneumothorax is seen a calcified granuloma in the left midlung is unchanged course from admission discharge summary y o female with h o htn hld presents with uri symptoms sore throat cough x few days and c o acute onset shortness of breath yesterday admitted for further eval uri upper respiratory infection acute hypoxia presented with day history of sore throat productive cough and acute onset sob she was hypoxic with o2 sat and with increased wob and she was treated with duonebs iv solumedrol and iv ctx and azithromycin with immediate improvement in her respiratory status wbc was and ct neck chest was notable for mild thickening of the aryepiglottic folds w recommendation for direct visual inspection ent consulted and performed a fiberoptic exam which showed mild erythema of oropharyngeal mucosa and mild erythema of bilateral arytenoids and posterior pharyngeal wall ent felt there was no need for steroids at this time from an upper airway perspective and steroids may in fact mask worsening of an infection started bid ppi initiate aspiration and reflux precautions and saline nebs to oral cavity q4h for humidification given smoking hx likely that patient has copd component albuterol written at discharge for continued expiratory wheeze off o2 discharged with rx for levofloxacin to complete course for presumed copd flare hypertension continued home hydralazine 25mg po tid losartan 50mg po daily clonidine 2mg q12 hours and carvedilol 25mg po bid bp on the morning of discharge and decreased to 180s most of the day team recommended patient stay in the hospital for blood pressure control and explained all of the risks of significantly elevated blood pressure including stroke cardiac issues and death patient adament that she wanted to leave and go home her son at bedside during this conversation we recommended that she call her pcp to schedule an appointment as soon as possible and she should check her blood pressure tonight and daily bp at discharge offered po hydral patient refused patient says she is going to take her home blood pressure medications as soon as she gets home signed ama discharge with interpreter present and son present rn also present for d c patient verbalized understanding of all of the risks of leaving the hospital including stroke cardiac issues and death also told to monitor for ha lightheadedness dizziness fainting chest pain at home hyperlipidemia continued atorvastatin 20mg po daily brief hospital course is a woman with copd poorly controlled htn gerd and former pack year history of smoking who presents with ongoing dyspnea and cough after recent brief admission to with the same suspect copd exacerbation triggered by viral illness copd with acute exacerbation suspected viral respiratory infection recent hypoxic respiratory failure while at oropharyngeal arytenoid pharyngeal erythema at patient presented to on with sore throat cough and dyspnea found to have hypoxia on room air initially treated with steroids and antibiotics although after ct raised concern for laryngeal edema she underwent laryngoscopy which showed erythema of oropharyngeal arytenoid and pharyngeal tissue steroids were stopped and patient started on ppi and levaquin as well as albuterol she returned to the day after her discharge with ongoing dyspnea and cough her sore throat had overall improved but she continued to have dyspnea and cough presenting with tachypnea in and initial peak flow of she received iv solumedrol and nebs in the ed and was started on copd flare treatment with a prednisone burst nebs zpack on the floor she improved significantly and was transitioned from scheduled nebs to scheduled albuterol inhaler with prn nebs she felt significantly improved and was discharged home she will complete day prednisone burst and zpack she was prescribed a nebulizer machine for home since she has difficulty inhaling albuterol when her symptoms worsen she was provided with a spacer for her inhaler a peak flow meter and incentive spirometer and teaching on using these recommend pfts as outpatient and consideration of long acting inhalers it was felt that her laryngoscopic findings of oropharyngeal arytenoid and pharyngeal erythema at were likely due to a viral illness given their improvement and occurrence along with other viral symptoms she will continue her prior daily ppi she was set up with for medication teaching and cardiopulmonary assessments uncontrolled hypertension followed by cardiology as outpatient for htn unfortunately her htn is worse controlled currently than at baseline possibly in the setting of her acute illness she was restarted on her home meds but had sbps in the 160s 200s and so hydralazine increased from to tid she will follow up with cardiology for further management hld continued home lipitor 20mg qpm ascvd prevention continued home baby asa gerd continued home omeprazole 40mg daily anxiety continued home doxepin 250mg qhs transitional issues outpatient pfts reinforce teaching on copd regimen consider long acting copd inhaled meds continue to titrate bp meds consider further work up of mild chronic alt elevation as outpatient if appropriate minutes in patient care and coordination of discharge medications on admission the preadmission medication list is accurate and complete losartan potassium mg po bid carvedilol mg po bid clonidine mg po bid hydralazine mg po tid atorvastatin mg po qpm omeprazole mg po daily aspirin ec mg po daily doxepin hcl mg po hs cyanocobalamin mcg po daily vitamin d unit po daily albuterol sulfate mcg actuation inhalation puffs s inhaled every four hours as needed for cough wheeze chest congestion short of breath mdi with dose counter polyethylene glycol g po daily senna mg po bid discharge medications azithromycin mg po q24h duration days rx azithromycin zithromax mg tablet s by mouth once a day disp tablet refills benzonatate mg po tid rx benzonatate mg capsule s by mouth three times a day disp capsule refills guaifenesin er mg po q12h rx guaifenesin mucinex mg tablet s by mouth twice a day disp tablet refills ipratropium albuterol neb neb neb q6h prn dyspnea wheezing use if unable to use albuterol inhaler rx ipratropium albuterol mg mg mg base ml dose inhaled up to four times daily as needed disp ampule refills prednisone mg po daily duration days rx prednisone mg tablet s by mouth once daily disp tablet refills hydralazine mg po tid rx hydralazine mg tablet s by mouth three times a day disp tablet refills albuterol sulfate mcg actuation inhalation puffs s inhaled every four hours as needed for cough wheeze chest congestion short of breath mdi with dose counter rx albuterol sulfate mcg puffs inhaled up to four times daily as needed disp inhaler refills aspirin ec mg po daily atorvastatin mg po qpm carvedilol mg po bid clonidine mg po bid cyanocobalamin mcg po daily doxepin hcl mg po hs losartan potassium mg po bid omeprazole mg po daily polyethylene glycol g po daily senna mg po bid vitamin d unit po daily nebulizer diagnosis copd discharge disposition home with service facility discharge diagnosis copd exacerbation viral respiratory infection hypertension 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 shortness of breath and a cough we suspect that your symptoms were due to a viral infection that caused a flare of your copd your symptoms improved with nebulizers steroids antibiotics and cough medications we recommend more days of the steroids prednisone and antibiotic azithromycin and a week of cough medication if you are still having a cough we have also prescribed a nebulizer machine that you can use at home we only recommend using this if you are too short of breath to use your albuterol inhaler effectively we also increased your dose of hydralazine due to continued high blood pressure you should continue monitoring this and follow up with your outpatient doctors followup instructions

name unit no admission date discharge date date of birth sex f service surgery allergies lisinopril percocet zestril duricef attending chief complaint bilateral hand pain left shoulder pain left rib pain major surgical or invasive procedure irrigation of laceration cm superficial laceration closed in layer with sutures of size ethilon suture material with good approximation history of present illness ms is a who presents following mechanical fall down steps at she reports that she only remembers parts of the fall and vaguely remembers climbing to the top of the stairs and returning to bed where she was found by her granddaughter at with blood on her hands she does not recall if she had headstrike or loc she was taken by her granddaughter to the where she underwent ct scan of her head cspine and xr of her ue and left shoulder identified injuries at the time of transfer to include left clavicle fracture multiple left rib fractures and multiple bilateral hand fractures got tdap and morphine osh past medical history past medical history htn hld traumatic dislocated shoulder past surgical history b l hip replacements l foot neuroma excision open cholecystectomy yrs ago social history family history nc physical exam admission physical exam temp hr bp resp o sat constitutional comfortable heent normocephalic atraumatic no c spine tenderness chest left chest wall tenderness to palpation cardiovascular regular rate and rhythm abdominal soft pelvic stable pelvis gu flank no costovertebral angle tenderness extr back no midline spine tenderness bilateral wrist splints in place with ecchymosis skin abrasions over the right thumb with ecchymosis neuro gcs psych normal mood discharge physical exam vs po ra heent no deformity perrl eomi neck supple trachea midline mucus membranes pink moist cv rrr pulm clear to auscultation bilaterally abd soft non tender non distended active bowel sounds x quadrants ext warm and dry ecchymotic left great toe ecchymotic bilateral hands bilateral hands in cast left great toe ecchymosis neuro a o x3 follows and moves all equal and strong speech is clear and fluent pertinent results imaging fast negative obtained at osh ct cspine head negative except for parietal scalp hematoma cxr left rib fx left clavicle xrays comminuted fracture of the left mid clavicle fracture of the lateral portion of the left and 3rd rib right hand xray fracture at the base of the second and possibly third metacarpal bone moderate to severe osteopenia left hand xray intra articular fracture at the base of the first metacarpal left humerus forearm negative ct chest abd pelvis acute left clavicular and left third through fifth rib fractures small left pneumothorax luminal irregularity and focal hypodensity in the left external jugular vein likely representing mural injury with nonocclusive thrombus secondary to the adjacent left clavicular fracture no active extravasation biliary ductal dilatation potentially due to post cholecystectomy state left toe no great toe fracture or dislocation scattered mild degenerative changes midfoot forefoot 25am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 25am blood plt 25am blood ptt 45am blood glucose urean creat na k cl hco3 angap 25am blood glucose urean creat na k cl hco3 angap 25am blood alt ast alkphos amylase totbili 25am blood calcium phos mg brief hospital course ms is a yo f who was admitted to the acute care trauma surgery service on after a fall she was transferred from an outside hospital and found to have a left clavicle fracture left sided rib fractures small left pneumothorax left intra articular fracture at the base of the first metacarpal and right base of the second and probably third metacarpal bone there was an incidental finding of a biliary ductal dilatation she was hemodynamically stable and admitted to the surgical floor for further management orthopedic surgery was consulted for the left clavicle fracture recommended non operative management and outpatient follow up hand surgery was consulted for the bilateral hand fractures and placed spica splints the laceration was washed out and repaired with sutures the right had will be managed non operatively and the left hand will be surgically fixated as an outpatient she had an mrcp to further evaluate biliary ductal which showed no choledocholithiasis or periampullary mass she was seen and evaluated by occupational and physical therapy who recommended discharge to a rehabilitation facility the patient had adequate pain control with oral medication regimen diet was progressively advanced as tolerated to a regular diet with good tolerability the patient voided without problem during this hospitalization the patient ambulated early and frequently was adherent with respiratory toilet and incentive spirometry and actively participated in the plan of care the patient received subcutaneous heparin and venodyne boots were used during this stay at the time of discharge the patient was doing well afebrile with stable vital signs the patient was tolerating a regular diet ambulating voiding without assistance and pain was well controlled the patient was discharged home without services the patient received discharge teaching and follow up instructions with understanding verbalized and agreement with the discharge plan medications on admission atenolol 50mg daily losartan 50mg daily pravastatin mg po qpm discharge medications acetaminophen mg po tid docusate sodium mg po bid prn constipation hold for loose stool milk of magnesia ml po q8h prn constipation as needed tramadol mg po q4h prn pain take lowest effective dose atenolol mg po daily losartan potassium mg po daily pravastatin mg po qpm discharge disposition extended care facility diagnosis left rib fractures comminuted fracture of the left mid clavicle right side fracture at the base of the second and possibly third metacarpal bone left intra articular fracture at the base of the first metacarpal discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear ms you were admitted to the acute care trauma surgery service on after a fall you were found to have bilateral hand fractures a left clavicle fractures and left sided rib fractures there was an incidental finding of biliary duct dilation seen on ct scan you had an mri to further evaluate this change which was a normal you were seen by the hand surgeon for your hand fractures they recommend that you wear your splints your rehabilitation center will be notified with the appointment time for surgery on you were seen by the orthopedic team who recommended a sling for comfort for your clavicle fracture with gentle range of motion you were seen and evaluated by physical and occupational therapy who recommend discharge to rehabilitation you are now doing better tolerating a regular diet and pain is better controlled you are now ready to be discharged to rehab to continue your recovery please note the following discharge instructions rib fractures your injury caused left sided rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain 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 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 degrees fahrenheit or 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 continue to be non weight bearing on both hands until further notice from your hand surgeon avoid driving or operating heavy machinery while taking pain medications 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 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

name unit no admission date discharge date date of birth sex f service medicine allergies penicillins attending chief complaint s p fall major surgical or invasive procedure none history of present illness female with history of chf a fib on coumadin presenting from outside hospital with spinal fracture status post fall patient states that she was trying to use the bathroom yesterday when she slipped and fell onto her back she denies preceding symptoms and describes the fall as slipping she is unsure if she struck her head but does not think she lost consciousness she also reports a fall weeks ago getting out of the car when she landed on her left hip she has some pain in that area as well in the ed initial vitals ra labs were significant for cr unknown baseline inr on coumadin imaging showed t11 l2 compression fractures in the ed she received diltiazem extended release mg torsemide mg vitals prior to transfer nasal cannula currently she reports mild discomfort but denies pain she does not want to take pain medications unless needed she is worried that she is declining having had two falls in the last month past medical history right sided heart failure cirrhosis due to congestive hepatopathy atrial fibrillation on coumadin severe tricuspid regurgitation mds social history family history mother with history of heart disease physical exam admission exam vs po ra gen pleasant frail elderly woman in no distress heent dry mm anicteric sclerae ncat perrl eomi neck supple pulm ctab cor irregularly irregular no murmurs abd soft non tender non distended bs no hsm extrem warm well perfused chronic venous stasis changes w discoloration skin thickening present bilaterally neuro cn ii xii grossly intact motor function bilaterally sensation grossly intact discharge exam vs ra gen pleasant frail elderly woman in no distress heent mmm anicteric sclerae ncat perrl eomi neck supple prominent jvp pulm clear to auscultation bilaterally cor irregularly irregular no murmurs abd soft non tender non distended bs no hsm extrem warm well perfused chronic venous stasis changes w discoloration skin thickening present bilaterally neuro cn ii xii grossly intact motor function bilaterally sensation grossly intact pertinent results admission labs 25pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 25pm blood ptt 25pm blood glucose urean creat na k cl hco3 angap 20am blood alt ast alkphos totbili 20am blood probnp imaging mri spine impression there is acute t11 compression fracture with mild vertebral body height loss mild central canal narrowing there is acute l2 compression fracture with severe vertebral body height loss and moderate to severe thecal sac effacement at this level with contribution from epidural lipomatosis there are multilevel degenerative changes suggestion of arachnoiditis at l3 l4 level there are small bilateral pleural effusions small volume free fluid in the pelvis ct c spine impression no evidence of fracture or traumatic malalignment degenerative changes as above ct head impression streak artifact from dental amalgam slightly limits evaluation no evidence of intracranial hemorrhage or calvarial fracture please refer to the ct cervical spine report of the same date for further findings cxr impression marked enlargement of the cardiac silhouette cm irregular appearing nodular opacity over the left upper to mid lung with possible spiculated margins concerning for pulmonary lesion recommend nonemergent chest ct for further assessment micro urine culture final no growth discharge labs 25am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 25am blood 25am blood glucose urean creat na k cl hco3 angap 25am blood calcium phos mg brief hospital course ms is a with history of severe tricuspid regurgitation resulting in chronic right sided heart failure and cirrhosis due to congestive hepatopathy atrial fibrillation who presents after a fall she reports that she slipped in the bathroom and fell onto her back she underwent head ct and c spine ct that showed no abnormalities however ct of the thoracic and lumbar spine showed acute t11 and l2 fractures she underwent mri which did not show any spinal cord impingement she was evaluated by the orthopedic spine team and did not require surgical intervention she was encouraged to use a tlso brace when out of bed she was evaluated by with plan for rehab her oxybutynin was stopped due to risk of precipitating falls given falls in the last mo labs drawn in the hospital revealed acute kidney injury with cr from baseline of this was thought to be most likely due to over diuresis from recent increases in her diuretic regimen as she was below her typical dry weight pounds cardiology was consulted and recommended stopping metolazone they also felt that tricuspid valve repair was unlikely to be of benefit to her but that further evaluation could be done as an outpatient she was scheduled for an appointment with dr on to discuss further acute issues t11 and l2 compression fractures she was found to have t11 and l2 compression fractures on imaging mri did not show spinal cord impingement she was evaluated by orthopedic spine and was not felt to need surgical intervention she should wear a tlso when out of bed chronic right sided heart failure due to severe tricuspid regurgitation she has severe tr resulting in right sided heart failure and resultant cirrhosis there was discussion as outpatient regarding possibility of transcutaneous repair she was evaluated by cardiology during this hospitalization and thought to be over diuresed her home metolazone was stopped and torsemide was continued she was set up with an outpatient appointment with dr structural heart to determine whether she might be a candidate for repair or replacement of her tricuspid valve on ckd cr from a baseline of as her weight was below her baseline and by her report her edema was greatly improved this was thought to be due to over diuresis her metolazone was stopped her cr improved to by the time of discharge s p fall she presented after a mechanical fall she had no preceding symptoms or loss of consciousness there was no evidence of infection her oxybutynin was stopped as this can precipitate falls in the elderly she was evaluated by and recommended for rehab chronic issues cirrhosis due to congestive hepatopathy she has cirrhosis likely due congestion from her right sided heart failure lfts are at recent baseline thrombocytopenia mds she has a history of mds and chronic thrombocytopenia as a result this was stable atrial fibrillation adequately rate controlled on current regimen chads2vasc therapeutic on warfarin she was continued on warfarin 2mg po daily atenolol was switched to metoprolol given renal dysfunction diltiazem was continued lung lesion spiculated 1cm lung lesion in left upper lobe noted on cxr ct chest recommended for further evaluation urinary incontinence stopped oxybutynin due to repeated falls transitional issues discharge weight kg atenolol was stopped due to worsening renal function metoprolol was started metolazone was stopped due to concern for overdiuresis causing oxybutynin was stopped due to risk of causing falls spiculated 1cm lung lesion in left upper lobe noted on cxr will need chest ct for further workup code status dnr dni confirmed contact sons time in care greater than minutes in patient care patient counseling care coordination and other discharge related activities on the day of discharge medications on admission the preadmission medication list is accurate and complete diltiazem extended release mg po daily metolazone mg po daily torsemide mg po daily atenolol mg po daily folic acid mg po daily magnesium oxide mg po daily multivitamins tab po daily oxybutynin mg po qhs warfarin mg po daily16 calcium d calcium carbonate vitamin d3 mg calcium unit oral daily discharge medications acetaminophen mg po q8h prn pain mild metoprolol succinate xl mg po daily calcium d calcium carbonate vitamin d3 mg calcium unit oral daily diltiazem extended release mg po daily folic acid mg po daily magnesium oxide mg po daily multivitamins tab po daily torsemide mg po daily warfarin mg po daily16 rolling walker pediatric rolling walker dx recurrent falls prognosis good months discharge disposition extended care facility discharge diagnosis primary diagnosis t11 and l2 compression fractures s p fall acute on chronic renal failure secondary diagnosis cirrhosis due to congestive hepatopathy chronic right sided heart failure due to severe tricuspid regurgitation atrial fibrillation discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear ms you were hospitalized at after a fall you fractured two vertebrae you should use the tlso brace when you are out of bed you were evaluated by the cardiology team we stopped the metolazone you should keep taking the torsemide you can follow up with dr as an outpatient to discuss the idea of fixing the tricuspid valve you will be discharged to a rehab to help improve your strength before going home we wish you the best your team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies benadryl dilaudid tylenol attending chief complaint dyspnea major surgical or invasive procedure none history of present illness with pmh cad s p cabg in with lvef atrial fibrillation and mgus smoldering myeloma who presented with dyspnea and was found to have a pe she had previously been on warfarin for atrial fibrillation in she had a severe fall resulting in multiple fractures wrist neck pelvis and facial fractures she required several transfusions and her warfarin was stopped she also had a recent hospitalization for heart failure at that time she was told her lvef was and she was diuresed with 20lb of fluid removed she was not sent home on any diuretics her daughter reports that there was a thought that she may have been overdiuresed her weight at time of discharge was 105lb most recently her weight had been around 110lb she has been having several days of malaise vague sense of feeling weak and unwell she had dyspnea on exertion that progressed to dyspnea at rest she is only able to walk 60ft before feeling short of breath she denies any orthopnea she sleeps on two pillows which has not recently changed she reports that her breathing improves after lying down she denies chest pain headache presyncope visual changes paresthesias or weakness at she was given zosyn asa and started on a heparin drip in the ed initial vitals ra labs were notable for k repeat whole blood hco3 bnp troponin bedside us revealed acute on chronic right heart strain on transfer vitals were ra on arrival to the micu she denied any shortness of breath or chest pain review of systems per hpi denies fever chills night sweats recent weight loss or gain denies headache sinus tenderness rhinorrhea or congestion denies cough shortness of breath denies chest pain or tightness palpitations denies nausea vomiting diarrhea constipation or abdominal pain no recent change in bowel or bladder habits no dysuria denies arthralgias or myalgias past medical history smoldering multiple myeloma vs mgus never on treatment fractures as per hpi persistent af dccv years with persistent af cad s p cabg and mitral valve repair years prior social history family history negative for any history of hypercoagulability physical exam admission exam vitals t bp p r o2 ra general alert oriented no acute distress neck supple ej distended and elevated to level of jaw at degrees lungs scant bibasilar crackles and crackles over r mid lung cv irregularly irregular tachycardic no murmurs rubs gallops abd soft non tender non distended no rebound tenderness or guarding ext b l peripheral edema r l cool extremities neuro moving all extremities cn grossly intact discharge exam vs on ra gen alert oriented to name place and situation fatigued appearing but comfortable no acute signs of distress heent ncat pupils equal and reactive sclerae anicteric op clear mmm neck supple no jvd lymph nodes no cervical supraclavicular lad cv s1s2 reg rate and rhythm no murmurs rubs or gallops resp good air movement bilaterally no rhonchi or wheezing abd soft non tender non distended bowel sounds extr trace leg edema derm no active rash neuro non focal psych appropriate and calm pertinent results admission labs 33pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 33pm blood neuts monos eos baso nrbc im absneut abslymp absmono abseos absbaso 30pm blood glucose urean creat na k cl hco3 angap 36pm blood alt ast ck cpk alkphos totbili 36pm blood calcium phos mg pertinent results labs 30pm blood imaging bilateral lower extremity dopplers deep vein thrombosis involving the left common femoral vein deep femoral vein and popliteal vein no evidence of dvt in the right lower extremity tte the left atrium is moderately dilated a large 2cm minimally mobile thrombus clip is seen in the body of the left atrium at the entrance of the left atrial appendage a second very large mural based thrombus vs wall of the left atrium clips is seen at the apex of the left atrium no atrial septal defect is seen by 2d or color doppler the estimated right atrial pressure is mmhg left ventricular wall thicknesses and cavity size are normal there is severe global left ventricular hypokinesis lvef the right ventricular cavity is mildly dilated with focal hypokinesis of the apical free wall the diameters of aorta at the sinus ascending and arch levels are normal the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic stenosis trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened a mitral valve annuloplasty ring is present the mitral annular ring appears well seated with normal gradient moderate tricuspid regurgitation is seen there is mild moderate pulmonary artery systolic hypertension significant pulmonic regurgitation is seen the end diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension there is a trivial physiologic pericardial effusion impression biatrial enlargement with two large thrombi in the body of the left atrial thrombi right ventricular cavity dilation with free wall hypokinesis severe global left ventricular hypokinesis normal functioning mitral annuloplasty ring mild moderate pulmonary artery hypertension discharge labs 30am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30am blood ptt 30am blood glucose urean creat na k cl hco3 angap 30am blood calcium phos mg year old woman with history cad s p cabg in systolic chf with lvef atrial fibrillation and mgus smoldering myeloma who presented to with dyspnea and was found to have pulmonary embolism and deep venous thrombosis the patient had atrial fibrillation with rvr cardiology was consulted and recommended initiating digoxin for rate control pulmonary embolism deep venous thrombosis she was found to have a pulmonary embolism at and was initiated on a heparin gtt and transferred to lenis here showed deep vein thrombosis involving the left common femoral vein deep femoral vein and popliteal vein tte was obtained that revealed lvef and biatrial enlargement with two large thrombi in the body of the left atrial appendage right ventricular cavity dilation with free wall hypokinesis severe global left ventricular hypokinesis she was initially managed with heparin which was transitioned to enoxaparin as a bridge to warfarin which she was previously on for her atrial fibrillation but has been off since a fall in her cardiology practice has clinic where she has been followed in the past so we have asked her to re establish care with them and have asked the to fax her inr checks to dr her cardiologist who manages her coumadin who has been notified by phone she has an appointment with dr coming her inr on discharge was atrial fibrillation with rvr she developed atrial fibrillation with rvr while in the icu and cardiology recommended digoxin due to low blood pressure however once her rate was controlled her bp normalized and digoxin was discontinued in favor of uptitrating metoprolol her metoprolol was increased to mg daily which she tolerated ventricular tachycardia patient had beat runs of asymptomatic vt intermittently cardiology recommended uptitration of metoprolol which was accomplished electrolytes were repleted she will be discharged on mg metoprolol daily cad s p cabg and mvr cardiologist is dr patient was continued on aspirin metoprolol she will follow up with cardiology after discharge as noted above chronic systolic heart failure ef not on diuretics or ace i at home as she had a recent hospitalization where it was felt she may have been overdiuresed wasn t sent home on any diuretics she was euvolemic to mildly overloaded so did not start any diuresis while patient was admitted she had a cough with lisinopril in the past so was changed to losartan daughter isn t certain what happened to this medication we have advised her to discuss restarting losartan with dr on if her bp remains above systolic mgus myeloma patient should followup with pcp and oncologist transitions of care follow up her cardiology practice has clinic where she has been followed in the past so we have asked her to re establish care with them and have asked the to fax her inr checks to dr her cardiologist who manages her coumadin she has an appointment with dr coming we have advised her to discuss restarting losartan with dr on if her bp remains above systolic she should follow up with her pcp within one week enoxaparin should be stopped once inr is code status full code medications on admission the preadmission medication list is accurate and complete metoprolol tartrate mg po bid discharge medications metoprolol succinate xl mg po daily rx metoprolol succinate mg tablet s by mouth daily disp tablet refills warfarin mg po daily16 rx warfarin mg tablet s by mouth daily disp tablet refills enoxaparin sodium mg sc q12h start today first dose next routine administration time please stop this medication once inr rx enoxaparin lovenox mg ml injection sc twice a day disp syringe refills aspirin mg po daily rx aspirin mg tablet s by mouth daily disp tablet refills docusate sodium mg po bid rx docusate sodium mg capsule s by mouth twice a day disp capsule refills senna mg po bid prn constipation rx sennosides senna mg tab by mouth daily disp capsule refills outpatient lab work please check inr on and as needed afterwards to get warfarin to correct dosing based on inr discharge disposition home with service facility discharge diagnosis pulmonary embolism submassive dvt of left common femoral vein deep femoral vein and popliteal vein atrial fibrillation with rapid ventricular response discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear dr was a pleasure to care for you during your recent admission to you were found to have a blood clot in your lungs called a pulmonary embolism pe and in your leg called a deep vein thrombosis dvt we started blood thinning medicine to help dissolve the clot and you are going home back on coumadin you should call your clinic on to re initiate care with them we have asked your visiting nurse to check your coumadin inr level on and fax the results to dr office you should stay on coumadin indefinitely you also had an abnormal rhythm called ventricular tachycardia intermittently during your admission your beta blocker metoprolol was increased in dosage to help suppress this rhythm it is important that you continue to take your medications as prescribed and follow up with the appointments listed below followup instructions

name unit no admission date discharge date date of birth sex m service cardiothoracic allergies lisinopril attending chief complaint sob left sided cp major surgical or invasive procedure ct guided placement of left pleural pigtail catheter bronchoscopy with attempted ebv placement left thoracoscopy lysis of adhesions resection of bleb pleurodesis and creation of subcutaneous vent history of present illness mr is a y o m with a h o cad afib on xarelto pneumothorax approximately years prior chronic kidney disease niddm who presents as transfer from osh after being found to have a pneumothorax chest pain began approximately although patient unsure the initial pain was associated with dyspnea and prompted him to present to his primary care provider who referred him to cxr on presentation there was notable for large left pneumothorax constituting at least of the hemithorax volume with significant left lung volume loss and very early mild tension component in light of this finding a pigtail catheter was placed on the left he was monitored with serial chest xrays and at lest check on there was a small pneumothorax at the lung apex extending laterally new from the prior exam pneumothorax estimated at no mediastinal shift given persistent pneumothorax patient transferred to for ip evaluation following pulmonary consult additionally patient reports that his right lower extremity also got swollen a week ago negative for dvt reports that he has had phlebitis in both legs in which improved his right lower extremity started with increased redness and swelling again a week ago he also had some chills a week ago patient denies any trauma or strenuous activity given concern for lower extremity cellulitis for which he was started on cefazolin with improvement in his symptoms past medical history copd cad reports mi at age afib on xarelto pneumothorax chronic kidney disease niddm social history family history no known lung pathology physical exam temp bp hr rr o2 sat ra wt lb kg gen nad heent moist mm eomi neck supple lungs cta decreased breath sounds on left at apex chest pigtail catheter in place no erythema surrounding cv rrr gi abd soft nt nd rectal deferred gu deferred skin erythema to mid shin on right lower extremity mild warmth neuro alert x no focal deficits musc joints without swelling or tenderness psych appropriate pertinent results wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct glucose urean creat na k cl hco3 angap cxr the small left apical pneumothorax has increased slightly in size measuring up to mm previously mm when measured with similar technique a left mid chest pigtail drainage catheter projects in unchanged location with associated subcutaneous emphysema retrocardiac opacification is similar to the prior study and likely represents atelectasis there is no pulmonary edema the cardiomediastinal silhouette is stable chest ct when comparing with prior study there is inversion of the left diaphragmatic mass effect over the heart and mediastinum and an increase in the amount of left pneumothorax the pneumothorax appears to be under tension of note there is a kink in the left pleural drain new left lateral chest wall subcutaneous emphysema noted cxr there has been decrease in the subcutaneous emphysema throughout the chest wall there is again seen a left sided chest tube with distal tip projecting over the lung apex there is a small left apical pneumothorax which may have been present on the prior study endotracheal tube and feeding tube have been removed there is a left retrocardiac opacity and likely left sided pleural effusion right lung is clear cxr heart size and mediastinum are stable substantial amount of subcutaneous air is present left retrocardiac atelectasis is unchanged there is minimal amount of left apical pneumothorax suspected overall no change since previous examination detected brief hospital course mr was evaluated by the medical service in the emergency room and admitted to the hospital for further management of his left pneumothorax his pigtail catheter was on suction and a large air leak was noted but his chest xray showed incomplete expansion of the lung on he went to for a ct guided left pleural pigtail catheter which was attached to cm suction his air leak persisted and the lung was slightly better expanded his xarelto was stopped in case any type of surgical intervention was needed the interventional pulmonary sevice was consulted for possible endobronchial valve placement and that was attempted on but was unsuccessful his air leak gradually decreased over time and decreased amounts of suction were applied to his chest tube he finally underwent a waterseal trial on but developed significant subcutaneous emphysema involving his left chest neck face including both eyes and his voice was high pitched the tube was placed back on cm suction to help decrease some of the subcutaneous emphysema which helped but at that point surgery was recommended on he was taken to the operating room where he underwent a left thoracoscopy lysis of adhesions resection of blebs pleurodesis and creation of subcutaneous vent he tolerated that procedure well and returned to the sicu intubated and in stable condition he remained intubated overnight but was easily extubated on the morning after surgery his chest tube was on cm suction and had an air leak he remained on suction for hours and his chest xray showed almost full expansion of his left lung he had a left infraclavicular incision in the or to help relieve some of the subcutaneous emphysema and a wound vac was placed on the site the vac helped relieve the crepitus in his face eyes neck and chest over a few days as his air leak gradually resolved he underwent a successful clamp trial on and his chest tube then removed his vac was removed on and the area is loosely packed with a moistened and dsd until it heals by secondary intention his chest xray has been stable with a tiny left apical pneumothorax his oxygen saturations range from his blood sugars have ranged post op but his metformin and glipizide were held until his creatinine recovered peak current he was covered with regular insulin but now that his creatinine is back to baseline both drugs were resumed on urinary retention has been an issue post op and despite being back on his flomax and increasing his activity he s required multiple straight caths and failed voiding trials on a foley catheter was placed to a leg bag and he will follow up in the next week for a voiding trial ua and uc are pending at the time of this summary after a longer than expected stay he was discharged to home with services for his wounds care suture removal and foley catheter teaching he was discharged on and will follow up in the next week and with dr in weeks medications on admission the preadmission medication list is accurate and complete torsemide mg po daily tamsulosin mg po qhs omeprazole mg po bid glipizide mg po bid metformin glucophage mg po bid losartan potassium mg po daily zolpidem tartrate mg po qhs rivaroxaban mg po daily levothyroxine sodium mcg po daily metoprolol succinate xl mg po daily discharge medications acetaminophen mg po q8h rx acetaminophen mg tablet s by mouth every eight hours disp tablet refills atorvastatin mg po qpm docusate sodium mg po bid rx docusate sodium mg capsule s by mouth twice a day disp capsule refills lidocaine patch ptch td qam rx lidocaine patch once a day disp patch refills oxycodone immediate release mg po q6h prn pain moderate rx oxycodone mg tablet s by mouth every six hours disp tablet refills allopurinol mg po daily glipizide mg po daily levothyroxine sodium mcg po daily losartan potassium mg po daily metformin glucophage mg po daily metoprolol succinate xl mg po daily start omeprazole mg po bid rivaroxaban mg po daily tamsulosin mg po qhs torsemide mg po daily zolpidem tartrate mg po qhs discharge disposition home with service facility discharge diagnosis primary diagnosis persistent left pneumothorax with subcutaneous emphysema urinary retention secondary diagnosis atrial fibrillation coronary artery disease non insulin dependent diabetes mellitus chronic kidney disease discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted to the hospital for management of your left pneumothorax and ultimately required surgery you ve recovered well and are now ready for discharge continue to use your incentive spirometer times an hour while awake check your incisions daily and report any increased redness or drainage cover the area with a gauze pad if it is draining your chest tube dressing may be removed on if it starts to drain cover it with a clean dry dressing and change it as needed to keep site clean and dry there are some chest tube stitches in place that will be removed by the on the left anterior chest wound will close gradually from inside out no stitches you will need daily dressing changes until the area is healed you are also going home with a bladder catheter in place which will remain in until you see urology next week it will keep your bladder decompressed and should make the next voiding trial easier the catheter is hooked up to a leg bag and you can empty that times a day directly in the toilet by opening the spout you may shower with this in place you may need pain medication once you are home but you can wean it over the next week as the discomfort resolves make sure that you have regular bowel movements while on narcotic pain medications as they are constipating which can cause more problems use a stool softener or gentle laxative to stay regular no driving while taking narcotic pain medication take tylenol on a standing basis to avoid more opiod use continue to stay well hydrated and eat well to heal your incisions no heavy lifting lbs for weeks shower daily wash incision with mild soap water rinse pat dry no tub bathing swimming or hot tubs until incision healed no lotions or creams to incision site walk times a day and gradually increase your activity as you can tolerate call dr if you experience fevers or chills increased shortness of breath chest pain or any other symptoms that concern you followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies glyburide glucophage lexapro hydrochlorothiazide attending chief complaint gi bleed major surgical or invasive procedure intubation and mechanical ventilation egd and placement of femoral arterial line mesenteric arteriogram embolization of l gastric artery history of present illness mr is an with pmh afib aortic stenosis s p tavr on warfarin systolic heart failure ef on with clean cors in ckd stage iii iv iddm moderate copd who presented to on with a chief complaint of gi bleed on morning was otherwise in good health at his assisted living facility until after having a bowel movement he did not notice if the bowel movement was dark or bloody after using the bathroom he took about steps felt extremely dizzy and fell to the ground without losing consciousness he was able to contact the nurse on the facility who then contacted the ambulance at on arrival to was noted to have an sbp in the he was admitted to icu and placed on phenylephrine there for further management lab data there notable for supratherapeutic inr at and hct pt was transfused 5uprbc to temporary improvement but his hct dropped again to at that point his inr was reversed with ffp and vitamin k gi tried to place an ng tube but failed pt was put on a ppi and amiodarone gtt as he was tachycardic gi did not feel comfortable scoping pt there so he was transferred to for further management he confirms that he usually has regular bowel movements every morning denies having a history of gi bleed denies ever having a colonoscopy or egd done in his past denies any recent sickness no fevers chills flu like symptoms diarrhea in the past week past medical history severe critical as acute on chronic diastolic systolic hf with last ef ckd stage iii iv gfr afib no anticoagulation bicuspid aortic valve copd moderate pulmonary htn htn diabetes type on insulin hyperlipidemia pancreatitis anemia kidney stones c diff colitis distant history of c diff colitis bph macular degeneration urethral stricture has a congenital stricture that requires small bore foley catheter per urology try for one pass if unsuccessful call urology for placement of pediatric catheter social history family history no family history of early mi arrhythmia cardiomyopathies or sudden cardiac death physical exam admission exam vitals 2l general no respiratory distress nontoxic appearance a ox3 pleasant mood heent at nc eomi pupils unequal with l r by approximately 1mm left pupil slightly oval shaped neck no jvd at degrees cardiac tachycardic and irregular rhythm normal 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 extremities with purpose pulses dp pulses bilaterally neuro cn ii xii intact discharge exam expired pertinent results admission labs 54pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 54pm blood neuts lymphs monos eos baso nrbc im absneut abslymp absmono abseos absbaso 54pm blood ptt 54pm blood ret aut abs ret 54pm blood glucose urean creat na k cl hco3 angap 54pm blood calcium phos mg 00pm blood po2 pco2 ph caltco2 base xs 00pm blood lactate 00pm blood o2 sat microbiology none studies cxr picc line in place significant interval improvement in cardiopulmonary findings gi embolization successful embolization of the left gastric artery with stasis on post embolization angiogram successful left common femoral vein central venous line placement and left common femoral artery arterial line placement ct head non contrast no evidence of hemorrhage bilateral cerebellar hemisphere hypodensities some of which appear well defined are concerning for infarcts age indeterminate but some may be more chronic probable sequelae of chronic small vessel ischemic disease prominent asymmetric right extra axial space could be from cortical atrophy or chronic hygroma no midline shift discharge labs 55am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 55am blood ptt 55am blood 55am blood glucose urean creat na k cl hco3 angap 55am blood calcium phos mg 42am blood vanco 14am blood type art po2 pco2 ph caltco2 base xs 14am blood lactate 14am blood freeca brief hospital course brief summary mr is an with pmh afib aortic stenosis s p tavr on warfarin systolic heart failure ef on with clean cors in ckd stage iii iv iddm moderate copd who was transferred from for a brisk gi bleed s p units prbc at acute issues gi bleed anemia no prior history of gi bleed but confirmed prior history of hemorrhoids no prior egd or colonoscopy per patient history did not notice dark or bloody stools until arriving to the hospital no nausea or vomiting and was protecting his airway adequately during his hospitalization given at least 9uprbc at the outside hospital prior to arrival here was given a total of 13uprbc during his hospitalization here as well as 9u platelets and 9uffp started on iv pantoprazole bid and aminocaproic acid underwent upper endoscopy with gi early in his hospital course for which he was intubated upper endoscopy showed old blood in stomach but otherwise no acute bleeding source team took patient down for angiography and found no obvious target of bleeding which initially showed no area of active extravasation blood volume continued to remain unstable on pt went again to and underwent a l gastric artery embolization his bleeding slowed but he continued to require blood transfusions as above subsequent upper endoscopy on notable for ischemic gastric mucosa pt developed a two pressor requirement norepinephrine and vasopressin he was placed on octreotide and desmopressin for splanchnic vasoconstriction and improvement of uremic platelet dysfunction see below respectively per discussion with family pt was made dnr dni and transitioned to comfort focused care on pt was extubated and passed away on hfref ef in cvo2 and lactate on admission likely a combination of severe anemia and borderline shock on clinical examination appears euvolemic and not in acute heart failure initially held his torsemide metoprolol digoxin lisinopril and tamsulosin in setting of low bps and had fluid overload in setting of multiple blood transfusions which was tolerated due to need to maintain stable blood volume altered mental status pt was initially sedated for his intubation with propofol and pain controlled with fentanyl taken off propofol on but continued to remain unresponsive and unable to follow commands ct head on demonstrated bilateral cerebellar hemispheric hypodensities concerning for infarct though time course indeterminate amicar discontinued in the setting of possible ischemic event atrial fibrillation with rvr inr goal given frequent episodes of supratherapeutic inr on warfarin supratherapeutic inr of on initial presentation to osh reversed at osh with inr upon arrival to warfarin and metoprolol were held in setting of active gi bleed and low bps thrombocytopenia dilutional and active consumption of platelets likely etiologies required frequent transfusions of platelets as above to prevent further dilutional thrombocytopenia started on desmopressin given rising uremia in setting of acute on chronic kidney injury to improve platelet dysfunction anion gap and non gap metabolic acidosis downtrending bicarb in setting of shock ckd lactate initially increased on admission to a peak of but normalized diabetes reasonably well controlled possible contributors included renal failure hyperchloremia plus ongoing bloody output from rectal tube hypernatremia given d5 to replete free water deficit iddm home levemir novolog started on lantus sliding scale during hospitalization acute on ckd stage iii iv cr on admission with baseline around likely prerenal given low bps and active bleeding has received volume back with blood and platelet transfusion but with persistent fluid overload in setting of holding diuretics creatinine trended up to a peak of chronic issues copd continued home inhalers without changes transitional issues code dnr dni contact name of health care proxy relationship daughter phone number on admission the preadmission medication list is accurate and complete aspirin mg po daily stiolto respimat tiotropium olodaterol mcg actuation inhalation daily warfarin mg po daily16 allopurinol mg po daily digoxin mg po daily ferrous sulfate mg po daily finasteride mg po daily lisinopril mg po daily multivitamins tab po daily tamsulosin mg po qhs calcium carbonate mg po tid vitamin d3 cholecalciferol vitamin d3 unit oral daily simvastatin mg po qpm torsemide mg po daily metoprolol succinate xl mg po bid pantoprazole mg po q24h levemir insulin detemir unit ml subcutaneous unknown novolog insulin aspart unit ml subcutaneous unknown discharge disposition expired discharge diagnosis deceased discharge condition deceased discharge instructions deceased followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies no known allergies adverse drug reactions attending chief complaint shortness of breath major surgical or invasive procedure tavr in ccu post procedure completed treatment of uti with antibiotics thrombin injection to left groin pseudoaneurysm developed low urine output and gradual increase in creatinine to a high of on strict i o s daily weights continued repeat u s of left femoral artery stable no resurgence of pseudoaneurysm started on nutritional supplements glucerna to help manage solutes e g sodium hyponatremia history of present illness mr is an year old male with pmhx signif for afib not on anticoagulation he had been trialed on coumadin but had difficulty managing his dosing and inrs and was trialed on eliquis but had bleeding and a significant increase in his creatinine after which it was discontinued with a plan to revisit anticoagulation following his tavr ckd stageiii iv insulin dependent dm type ii moderate copd and recent diagnosis of severe as with multiple recent hospitalizations for decompensated heart failure last ef on tee on who presented in chf exacerbation and is now s p tavr patient initially presented to ed on for worsening dyspnea and weakness he had previously been scheduled for tavr in the next few weeks but his tavr procedure was moved up in the setting of worsening systolic and diastolic hf during course of hospital stay patient was found to have small bilateral pleural effusions on initial cxr he had been getting diuresed gently due to pre load dependence he also has underlying hyponatremia seen chronically pre admission which has been improving throughout his hospital stay with fluid restriction the patient was most recently discharged from on after a day stay for worsening dyspnea and volume overload he has been experiencing dyspnea for the past years with an acute worsening in the past few months he says that he now cannot make it from his room in his assisted living facility to the dining room before getting severely dyspneic and having to take a break past medical history severe critical as acute on chronic diastolic systolic hf with last ef ckd stage iii iv gfr afib no anticoagulation bicuspid aortic valve copd moderate pulmonary htn htn diabetes type on insulin hyperlipidemia pancreatitis anemia kidney stones c diff colitis distant history of c diff colitis bph macular degeneration social history family history no family history of early mi arrhythmia cardiomyopathies or sudden cardiac death physical exam admission physical exam vs 6l face mask general after bipap thin yo gentleman in nad aaox3 conversational heent normocephalic atraumatic sclera anicteric perrl eomi conjunctiva were pink lips and oral mucosa dry and cracked neck supple jvp of cm soft tender tissue swelling by cm above left subclavian over access site scant blood on dressing cardiac pmi located in intercostal space midclavicular line irregular rhythm iii vi systolic murmur heard best at lsb 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 radial pulses bilaterally left hand slightly cool skin cm cyst at posterior neck pulses distal pulses palpable and symmetric discharge physical exam vs t hr rr bp ra physical exam gen no acute distress lying sitting in bed very pleasant neck jvd no jvd noted cv irregular iii vi systolic murmur chest lung sounds diminished bilaterally no crackles abd soft non tender bs bm extr no ankle edema extremities are warm well perfused with diffuse ecchymosis pulses bilaterally palpable access sites l groin site with large area of surrounding bruising without significant swelling improved over ecchymosis on anterior and medial aspect of thigh non tender no bruit area decreasing in size and improved over no bleed or bruit noted r groin site ota no drainage bleed or bruit noted diffuse ecchymosis thighs and distal left chest shoulder subclavian access site with large amount of bruising no significant swelling mildly tender to palpation skin intact over the incision site without bleeding or drainage appears to be developing keloid scarring skin warm dry neuro alert oriented x no focal deficits pertinent results cxr comparison chest radiograph findings a moderate left and small right pleural effusion are grossly unchanged cardiomediastinal silhouette is overall unchanged there is a background of mild pulmonary edema similar to prior there is no pneumothorax impression moderate left and small right pleural effusions background pulmonary edema similar to prior cardiac cath report tavr op report successful insertion of tavr cardiac echo the left atrium is mildly dilated the estimated right atrial pressure is at least mmhg there is mild symmetric left ventricular hypertrophy the left ventricular cavity size is normal there is mild global left ventricular hypokinesis lvef the right ventricular free wall is hypertrophied right ventricular chamber size is normal with moderate global free wall hypokinesis there is abnormal septal motion position consistent with right ventricular pressure volume overload the ascending aorta is mildly dilated a bioprosthetic aortic valve prosthesis is present the transaortic gradient is normal for this prosthesis a paravalvular jet of mild to moderate aortic regurgitation is seen the mitral valve leaflets are mildly thickened moderate mitral regurgitation is seen moderate to severe tricuspid regurgitation is seen there is moderate pulmonary artery systolic hypertension there is no pericardial effusion compared with the prior study images reviewed of aortic valve bioprosthesis now present mild to moderate paravalvular aortic regurgotation left ventricular ejection fraction significantly increased ultrasound examination unilat lower ext veins findings in the left groin is a x x cm pseudo aneurysm with a narrow rising from the left common femoral artery with to and fro flow throughout the pseudoaneurysm the adjacent common femoral vein is grossly patent there is atherosclerotic calcification impression x x cm left common femoral artery pseudoaneurysm with a mm neck follow up ultrasound post thrombin embolization comparison femoral vascular ultrasound a pseudoaneurysm embolization findings transverse and sagittal images were obtained of the left groin there is an oval complex structure seen in the left groin consistent with the embolized pseudoaneurysm this structure measures x x cm no vascular flow is identified within the structure on doppler imaging appropriate venous flow is seen in the left cfv appropriate arterial waveforms are seen in the left cfa impression thrombosed pseudoaneurysm visualized in the left groin admission labs 25am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 08pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 25am blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 08pm blood glucose urean creat na k cl hco3 angap 25am blood glucose urean creat na k cl hco3 angap 25am blood estgfr using this 08pm blood ck cpk 25am blood ck cpk 08pm blood ck mb ctropnt 25am blood ck mb ctropnt 08pm blood calcium phos mg ckd electrolyte panel trending 50am blood urean creat na k cl hco3 angap 45am blood urean creat na k cl hco3 angap 46am blood glucose urean creat na k cl hco3 angap 10am blood glucose urean creat na k cl hco3 angap 45am blood glucose urean creat na k cl hco3 angap 35am blood glucose urean creat na k cl hco3 angap 15pm blood glucose urean creat na k cl hco3 angap 15am blood urean creat na k cl hco3 angap 05am blood glucose urean creat na k cl hco3 angap 25pm blood urean creat na k cl hco3 angap 30am blood urean creat na k cl hco3 angap 07pm blood urean creat na k cl 45am blood urean creat na k cl hco3 angap 20am blood urean creat na k cl hco3 angap 20am blood 45am blood 50am blood 45am blood 46am blood ptt 10am blood ptt 45am blood plt 35am blood ptt 15pm blood 05am blood ptt discharge labs 20am blood hct plt 20am blood 20am blood urean creat na k cl hco3 angap year old male with pmhx of htn hld insulin dependent dm ii moderate copd acute on chronic systolic diastolic chf and critical as ckd stage iii iv gfr who was admitted in chf exacerbation diuresed and underwent tavr then transferred to ccu s p tavr for post procedure monitoring he was transferred back to the general floor on severe aortic stenosis nyha class iii iv ef the patient underwent tavr approach initially through left femoral with subsequent left subclavian cut down and placement of mm evolut r us post tavr tte showed well seated aortic valve without significant stenosis or regurgitation he developed a left shoulder hematoma after left subclavian cut down hemostasis was achieved and the patient remained neurovascularly intact he was started on aspirin mg and plavix daily he was started on coumadin and was given mg for two days with a rise to on he was then given mg on and his inr was his coumadin continued to be held thereafter at the time of this discharge summary it is anticipated that he may likely only need minimal coumadin daily to maintain a therapeutic inr this will be managed by his pcp on discharge from rehab the pcp should be contacted prior to discharge from rehab to establish services and inr management hyponatremia baseline to he dropped to while hospitalized his serum and urine osms were followed and he was given gentle fluids as appropriate nephrology was consulted he was placed on a tighter fluid restriction liters with strict i o s and daily weights with gradual improvement nutritional supplements were added on to help with solute intake glucerna given his history of insulin dependent diabetes he rose to on he was near euvolemic on with no lower extremity edema and no elevation of jvd stage iii baseline cr which was elevated post procedure this peaked at on and nephrology was involved and closely following from as noted above he was gently hydrated and felt to have been overdiuresed post procedure with tight fluid restriction thereafter and careful fluid management daily weights and i o s he was trending down to on and will continue to be carefully monitored creatinine was on and improved significantly his foley catheter was discontinued and he is due to void he will likely discharge to rehab when he is at or near his baseline creatinine currently expected to be he will follow up with nephrology in given his ckd an appointment will be established prior to his discharge from he will continue with a fluid restriction to be relaxed to liters on discharge with strict i o monitoring and daily weights this should continue at discharge from rehab as well chronic systolic diastolic heart failure he was originally admitted for acute on chronic systolic diastolic heart failure he has a history of multiple recent exacerbations most likely secondary to critical as cxr on admission showed some signs of overload though he was clinically well he was not given an given his ckd his home dose metoprolol was temporarily replaced with metoprolol mg q6 he was diuresed with lasix according to fluid status and his diuretic has been held while normalizing his renal function and sodium levels his home digoxin was discontinued on per the structural heart team it was felt he could be better managed for rate control with his atrial fibrillation on an increased dose of metoprolol this had been increased early in his stay but he had some episodes of low blood pressure this has since stabilized and at the time of this discharge summary his dose of metoprolol tartrate has been increased to mg tid he tolerated this well with stable blood pressures and heart rate in the s he was changed back to long acting toprol at the increased dose of mg bid if his heart rate and blood pressure hold he has room to increase the toprol to mg if needed his telemetry has remained stable in the the last several days no was added due to his renal function hypercarbia patient initially presented with co2 retention after tavr his blood gas improved after hrs bipap the hypercarbia was felt to be secondary to sedation and decreased inspiratory effort he improved clinically and was weaned from o2 and bipap uti urine culture on grew ceftriaxone sensitive proteus urine cx on was contaminated patient was being treated for a presumed uti with ceftriaxone in ed x he was started on bactrim three doses following admission then started on cipro for two doses and ultimately restarted on ceftriaxone x two doses which was completed no repeat ua was performed was also given doses of bactrim as well then received ciprofloxacin and atrial fibrillation poorly controlled with resting rates of and spikes to with activity while on mg toprol daily at the floor he was rate controlled with metoprolol xl at home most recently placed on metoprolol q6 pt was briefly tried on metoprolol qid but had bp decrease on chads2vasc of on his digoxin was discontinued per the structural heart team and his heart rate continued to re spike to the s with a stable blood pressure in the s systolic at this point he was started on metoprolol mg tid with a plan to transition to toprol xl mg bid at the time of discharge the patient had been on eliquis in the past but had episodes of epistaxis and elevated creatinine and decline in renal function and it was discontinued he had been on warfarin in the past but was confusing doses in his assisted living facility and his inr was difficult to manage initially he was anticoagulated with asa mg and plavix 75mg daily post operatively and the plavix was ultimately discontinued he was re started on coumadin at 5mg on and currently has a supratherapeutic inr of and his coumadin has been held it is anticipated he will not require high doses of coumadin given his renal function and risk of bleeding it should continue to be monitored daily and titrated to a simple daily dose when his inr stabilized he will follow up with both his pcp and on discharge from rehab inr on trending down to and respectively with no dose given on insulin dependent dm2 he reports using a sliding scale insulin at bedtime with levemir and a sliding scale which will be clarified prior to discharge from he will require close follow up with his pcp at discharge from rehab and should have tighter control surrounding his insulin management his home levemir dose of units for fsbs at was ordered to resume he reports episodes of am hypoglycemia in the past and should follow up with his pcp at discharge from rehab with an appointment to be established by rehab prior to his discharge there he should continue a sliding scale insulin scale included with his discharge reconciliation leukopenia possibly secondary to bactrim he had no signs of infection other than uti as above while admitted this was monitored but not intervened upon and normalized to on chronic and currently stable issues hld he was continued on his home simvastatin copd he was continued on his home albuterol inhalers prn bph he was continued on his home finasteride and tamsulosin medications on admission the preadmission medication list is accurate and complete finasteride mg po daily calcium carbonate mg po tid allopurinol mg po daily metoprolol succinate xl mg po daily digoxin mg po 3x week simvastatin mg po qpm ferrous sulfate mg po daily furosemide mg po daily multivitamins tab po daily pantoprazole mg po q24h tamsulosin mg po qhs vitamin d unit po daily tiotropium olodaterol mcg actuation inhalation daily albuterol inhaler puff ih q4h prn wheeze albuterol neb soln neb ih q6h prn wheeze insulin sc sliding scale insulin sc sliding scale using aspart insulin insulin sc sliding scale insulin sc sliding scale using levemir insulin discharge medications aspirin mg po daily rx aspirin mg tablet s by mouth once a day disp tablet refills warfarin mg po daily16 take mg check inr manage closely given history insulin sc sliding scale fingerstick breakfast lunch dinner bedtime insulin sc sliding scale using hum insulin metoprolol succinate xl mg po bid albuterol neb soln neb ih q6h prn wheeze albuterol inhaler puff ih q4h prn wheeze allopurinol mg po daily calcium carbonate mg po tid ferrous sulfate mg po daily finasteride mg po daily levemir insulin detemir units subcutaneous qhs prn for fsbs multivitamins tab po daily pantoprazole mg po q24h simvastatin mg po qpm tamsulosin mg po qhs tiotropium olodaterol mcg actuation inhalation daily vitamin d unit po daily held furosemide mg po daily this medication was held do not restart furosemide until follow up with cardiology manage daily wts fluid restr may need to give lower dose mg prn daily if needed discharge disposition extended care facility discharge diagnosis primary aortic stenosis secondary acute on chronic decompensated systolic dysfunction euvolemic at discharge urinary tract infection treated with antibiotics while hospitalized atrial fibrillation chronic discontinued digoxin increased dose of metoprolol tartrate hyponatremia now back at baseline acute kidney injury on chronic kidney disease improving with tighter fluid restriction daily weights strict intake and output measurement and nutrition supplements pseudoaneurysm left common femoral artery s p successful thrombin injection discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear mr you were admitted to the hospital because you were short of breath this happened because of tightness of one of your heart valves you underwent evaluation for a transaortic heart valve previously and were admitted for a heart valve replacement on you were also treated for a urinary tract infection which is now better while hospitalized you had an acute kidney injury on your underlying chronic kidney disease likely due to contrast dye from your procedure and multiple medications in addition you have been noted to have low sodium hyponatremia at admission and noted in the recent past you were placed on a fluid restriction and a low sodium diet which should continue at discharge you were weighed daily and your intake and output was closely measured you were placed on nutrition supplements to help with your sodium levels since you are diabetic this is glucerna as opposed to ensure supplements you should continue with a liter fluid restriction permanently at discharge your intake and output measured while at rehab and counted when at home this includes food that melts at room temperature jello ice cream popsicles you should weigh yourself daily and if your weight goes up lbs in one to two days contact your pcp or immediately nephrology followed you closely while here and given your kidney function status recommend that you follow with an outpatient nephrologist an appointment has been established for you with dr at this will help you to monitor and manage your kidney function along with your current other medical conditions such as your heart function while hospitalized your digoxin was discontinued and your metoprolol dose was changed at home you took mg twice daily and while here it was increased to short acting metoprolol mg three times daily if your heart rate remains stable you will be discharged on mg long acting toprol twice daily your lasix has been kept on hold following your acute kidney injury and you have remained euvolemic the last hours your scheduled lasix will not be resumed at discharge this will be re evaluated at a follow up appointment however you should continue with daily weights and close management of your fluid restriction and low sodium diet if any fluid needs to be diuresed we recommend a prn lasix dose given your medical history additionally you developed a pseudoaneurysm post procedure and underwent successful guided thrombin injection to embolize the pseudoaneurysm a repeat ultrasound to re assess the groin was performed and was found to remain stable you will be given medicines called coumadin and aspirin when you leave the hospital these medicines are important to prevent blood clots you had been tried on eliquis in the past due to your history of atrial fibrillation but had some bleeding and an increase in your creatinine and a decline in your kidney function at that time as well while at rehab the rehab will manage your coumadin with an inr goal of at discharge this will be managed by your pcp your pcp should be contacted prior to discharge from rehab so that visiting nurse and inr draws can be scheduled and coordinated your daily dose at discharge from is mg but your inr should be monitored at rehab closely as it has been high prior to your discharge from with your underlying kidney function and your history of difficult to manage inrs we recommend at a minimum mg coumadin daily and to check your inr and once stable on a chronic dose at least twice weekly until the facility is certain that you are stable on that regimen you should weigh yourself every morning call your doctor if your weight goes up more than lbs in hours continue a low sodium gram carb consistent diet with glucerna shakes two to three times daily you should maintain a liter fluid restriction daily your insulin home dose of levemir was held you indicated you were on a sliding scale for this at home along with a sliding scale insulin at home and you were maintained on a sliding scale insulin while at at discharge you will be discharged on your levemir scale and the sliding scale insulin while at you should follow up with your pcp as previously mentioned post discharge from rehab and review ongoing management of your blood glucose followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies glyburide glucophage lexapro hydrochlorothiazide attending chief complaint shortness of breath s p tavr major surgical or invasive procedure none history of present illness mr is an year old male with pmhx signif for afib not on anticoagulation in the past he had been trialed on coumadin but had difficulty managing his dosing and inrs and was trialed on eliquis but had bleeding and a significant increase in his creatinine after which it was discontinued now on warfarin s p tavr ckd stageiii iv insulin dependent dm type ii moderate copd and recent diagnosis of severe as with multiple recent hospitalizations for decompensated heart failure last ef on tee on now s p tavr on who is presenting as a transfer for sob per clinic notes he is lbs up and per the patient has not been able to take his mg of daily lasix as prescribed he notes increased fatigue leg swelling but denies cp fever chills diet soup pb js cereal milk black coffee med compliance states he was not getting his lasix while at rehab last discharge summary from here instructs him to hold his mg of lasix daily until he saw his cardiologist of note he had hyperkalemia to at rehab on and per his cardiology team his rehab was told to restart his lasix at mg daily in the ed initial vitals were nasal cannula ekg afib na ni lvh lateral twi labs studies notable for bnp of 23k wnl lfts h h of platelets of no leukocytosis bun cr of inr of ptt lactate of ua with rbc patient was given iv lasix and mg po metoprolol xl for a fib vitals on transfer nasal cannula on the floor he is using his accessory muscles to breath but says he is comfortable on 4l denies cp palpitations orthopnea or pnd past medical history severe critical as acute on chronic diastolic systolic hf with last ef ckd stage iii iv gfr afib no anticoagulation bicuspid aortic valve copd moderate pulmonary htn htn diabetes type on insulin hyperlipidemia pancreatitis anemia kidney stones c diff colitis distant history of c diff colitis bph macular degeneration urethral stricture has a congenital stricture that requires small bore foley catheter per urology try for one pass if unsuccessful call urology for placement of pediatric catheter social history family history no family history of early mi arrhythmia cardiomyopathies or sudden cardiac death physical exam admission exam vs 4l 1kg 136lbs general in nad oriented x3 mood affect appropriate heent ncat sclera anicteric perrl eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthelasma neck supple with jvp to ear at degrees cardiac tachycardic irregularly irregular lungs bibasilar crackles mild expiratory wheeze decreased throughout abdomen soft ntnd no hsm or tenderness extremities pitting edema to thighs slightly cool feet ankles skin no stasis dermatitis discharge exam vs t bp hr rr o2 on ra weight kg kg i o general elderly caucasian gentleman laying back in bed smiling and cooperative with exam heent ncat sclera anicteric neck jvp measured at 9cm h2o when laying at degrees in bed cardiac irregularly irregular normal rate no murmurs gallops rubs auscultated lungs crackles mildly improved to of the way up lung fields bilaterally abdomen soft ntnd no rebound or guarding extremities warm no pitting edema of lower extremities posterior tibialis pulses bilaterally pertinent results admission labs 33pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 33pm blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 33pm blood plt smr low plt ct 43pm blood ptt 33pm blood alt ast alkphos totbili 33pm blood 33pm blood ctropnt 33pm blood albumin 33pm blood vitb12 33pm blood tsh pertinent imaging cxr moderate to large left and small right pleural effusions are increased from echocardiogram the left atrial volume index is severely increased the right atrium is moderately dilated no atrial septal defect is seen by 2d or color doppler the estimated right atrial pressure is mmhg left ventricular wall thicknesses and cavity size are normal with severe global hypokinesis lvef intrinsic left ventricular systolic function is likely more depressed given the severity of mitral regurgitation there is no ventricular septal defect the right ventricular cavity is mildly dilated with moderate global free wall hypokinesis intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation an evolut aortic valve bioprosthesis is present and well seated the transaortic gradient is normal for this prosthesis mild aortic regurgitation is seen the mitral valve leaflets are mildly thickened moderate to severe mitral regurgitation is seen severe tricuspid regurgitation is seen there is severe pulmonary artery systolic hypertension in the setting of at least moderate to severe tricuspid regurgitation the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure there is a very small circumferential pericardial effusion there is a prominent left pleural effusion impression normal left ventricular cavity size with severe global hypokinesis moderate to severe mitral regurgitation severe tricuspid regurgitation well seated tavr with mild aortic regurgitation severe pulmonary artery systolic hypertension compared with the prior study images reviewed of global left ventricular systlic function is now reduced and the severity of mitral regurgitation and tricuspid regurgitation have increased the right ventricular cavity is also now dilated cxr small left pleural effusion minimally decreased left basilar opacification mildly improved improved right pleural effusion mildly improved pulmonary vascularity basilar opacity stable postoperative changes right picc line discharge labs 21am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 21am blood ptt 15pm blood glucose urean creat na k cl hco3 angap hx afib warfarin ckd iii iv t2dm mod copd recent diagnosis of severe as now s p recent admission for tavr here with acute on chronic schf exacerbation in stg of missed diuretic doses at rehab active issues schf acute on chronic nyha ii at baseline iii during acute exacerbation exacerbated due to missed diuretics at rehab ef previously but improved to post tavr repeat echo showed ef of note pre tavr cath with clean cors he briefly required a ccu stay for hypotension down to sbp s with a wbc of concerning for septic shock as no clear source was identified and pt s pressures improved he returned to the floor and continued with diuresis preload torsemide for goal even on neurohormonal blockade held toprol for borderline bps afterload lisinopril 5mg daily contractility digoxin daily level on device none discharge weight 8kg atrial fibrillation chadsvasc2 of anticoagulation warfarin 5mg daily goal inr rate control metoprolol held as above in setting of persistent weakness and orthostasis chronic resolved issues l foot hematoma initially concerning for foot abscess acs consulted ultrasound based on u s most likely hematoma no indication for drainage thrombocytopenia patient with persistent thrombocytopenia in our system stable check smear outpatient heme follow up ckd stage iii iv baseline cr currently renally dosed meds copd home albuterol inhaler held home tiotropium inhaler nonformulary can resume as outpatient given equivalent tiotropium inh daily salmeterol inh q12h while in house discontinued t2dm pt unaware of home insulin regimen medium iss a1c urethral stricture has a congenital stricture that requires small bore foley catheter per urology try for one pass if unsuccessful requires calling urology for placement of pediatric catheter hld home simvastatin bph home finasteride home tamsulosin deconditioning consult to help ambulate transitional issues code full contact name of health care proxy relationship daughter phone number pt to have a digoxin level checked on or to assess therapeutic adequacy pt has a congenital urethral stricture that necessitates urology placing any foley catheters medication changes discontinued metoprolol added digoxin increased warfarin to 5mg daily discontinued furosemide replaced with 40mg torsemide daily discharge weight 8kg medications on admission the preadmission medication list may be inaccurate and requires futher investigation albuterol inhaler puff ih q4h prn wheeze allopurinol mg po daily calcium carbonate mg po tid ferrous sulfate mg po daily finasteride mg po daily multivitamins tab po daily pantoprazole mg po q24h simvastatin mg po qpm tamsulosin mg po qhs aspirin mg po daily albuterol neb soln neb ih q6h prn wheeze tiotropium olodaterol mcg actuation inhalation daily vitamin d unit po daily metoprolol succinate xl mg po bid levemir insulin detemir units subcutaneous qhs prn warfarin mg po daily16 furosemide mg po daily discharge medications digoxin mg po daily rx digoxin mcg tablet s by mouth daily disp tablet refills lisinopril mg po daily rx lisinopril mg tablet s by mouth daily disp tablet refills torsemide mg po daily rx torsemide mg tablet s by mouth daily disp tablet refills warfarin mg po daily16 rx warfarin mg tablet s by mouth daily disp tablet refills albuterol neb soln neb ih q6h prn wheeze albuterol inhaler puff ih q4h prn wheeze allopurinol mg po daily aspirin mg po daily calcium carbonate mg po tid ferrous sulfate mg po daily finasteride mg po daily levemir insulin detemir units subcutaneous qhs prn multivitamins tab po daily pantoprazole mg po q24h simvastatin mg po qpm tamsulosin mg po qhs tiotropium olodaterol mcg actuation inhalation daily vitamin d unit po daily outpatient lab work i48 inr check please fax results to fax phone inr or should be verbally communicated outpatient lab work i50 chemistry digoxin level discharge disposition home with service facility discharge diagnosis primary systolic congestive heart failure acute on chronic exacerbation secondary aortic stenosis status post tavr diabetes mellitus benign prostatic hypertrophy 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 seen in our hospital because you were feeling short of breath and weak you told us that you had missed several doses of your water pill torsemide while at a rehab facility after your recent valve replacement it looked like you had accumulated some extra water so we helped to remove it with additional doses of water pill both by mouth and through the iv by the time we discharged you you appeared to be at a new dry weight of 8kg weigh yourself every morning call md if weight goes up more than lbs we wish you the best your care team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies nsaids non steroidal anti inflammatory drug ibuprofen novocain lovastatin pravastatin procaine attending chief complaint weakness syncope major surgical or invasive procedure none history of present illness with a background history of paroxysmal svt avnrt htn hld osteoporosis and oa presenting from her assisted living facility following an episode of possible unresponsiveness with associated weakness and nausea patient awoke this morning with palpitations sensation of heart beating fast which was consistent with prior episodes of svt checked her pulse with her monitor and found her heart rate to be has a supply of verapamil 40mg tablets for which she was informed to take one if she experienced symptoms as above took one tablet of same with resolution of her palpitations about one hour post however did report associated nausea and general weakness which she has experienced on past occasions post verapamil subsequently felt light headed when leaning forward and getting dressed so activated her life alert before blacking out was found mildly unresponsive sitting on her toilet by assisted living facility team which resolved without intervention no indication if event was associated with limb jerking but no evidence of tongue biting or incontinence no duration for loss of consciousness but patient had come to on arrival does report difficulty speaking immediately post event but associates this with a feeling of severe generalized fatigue rather than an inability to speak otherwise continued to have generalized fatigue but no focal neurological deficits headache or confusion ems on arrival noted a systolic bp in low 100s when she is normally mildly hypertensive at baseline in the ed initial vital signs were temp hr bp rr sao2 ra examination was notable for a pale appearing lady but otherwise with no abnormal findings labs included wbc hgb plt bun cr na k cl hco3 troponin urinalysis bland cxr demonstrated a subtle opacity within the left lung base which could be secondary to atelectasis however a superimposed infectious process can not be excluded ct head without evidence of acute large territorial infarction or hemorrhage or calvarial fracture ct cervical spine demonstrated no evidence of acute traumatic fracture or traumatic malalignment initial ekg at rate of sinus rhythm with normal axis normal pr interval and qtc of poor r wave progression but otherwise no ischemic changes repeat ekg at rate of sinus rhythm with normal axis normal pr interval and qtc of poor r wave progression but otherwise no ischemic changes patient was given 500ml ns in ed vitals on transfer were temp hr bp rr sao2 ra upon arrival to the floor the patient reports continued fatigue and nausea but symptoms are much improved from earlier today denies chest pain or shortness of breath throughout day before during and after the above events also does not report fevers productive cough lower urinary tract symptoms or abdominal pain patient was in her usual state of health prior to this morning eating and drinking without issue unsure if dehydrated but feels it is unlikely as she drinks large amounts of water review of systems as per hpi except for chronic intermittent diarrhea constipation associated with ibs otherwise negative past medical history episodic cardiac arrhythmia paroxysmal svt avnrt hypertension hypercholesterolemia elevated calcium level measured at month ago irritable bowel syndrome periodic diarrhea back pain s p orif l bimalleolar ankle francture osteoporosis osteoarthritis amiodarone induced hypothyroidism social history family history patient s father coronary artery disease died at age patient s mother heart valve dysfunction specifics unknown patient s daughter parathyroid gland removed physical exam exam on admission vs temp bp hr rr sao2 ra general pleasant appearing lady with no acute distress heent at nc eomi perrla anicteric sclera no conjunctival pallor mmm neck supple non tender no lad jvp flat cv bradycardic regular rhythm s1 s2 normal no murmurs rubs gallops resp ctab no wheeze crackles breathing comfortably without use of accessory muscles of respiration soft non tender no distention bs normoactive extremities moving all four extremities with purpose no lower extremity edema skin no rashes lesions neuro a o x3 cn ii xii intact strength in all extremities sensation intact exam on admission vs t hr bp rr ra general sitting up in bed well appearing nad heent at nc eomi perrla anicteric sclera no conjunctival pallor mmm neck supple non tender no lad jvp flat cv bradycardic regular rhythm s1 s2 normal no murmurs rubs gallops resp ctab no wheeze crackles breathing comfortably without use of accessory muscles of respiration normal bowel sounds soft non tender no distention extremities no lower extremity edema skin no rashes lesions neuro a o x3 cn ii xii grossly intact strength in all extremities sensation to touch intact in upper and lower extremities pertinent results labs on admission 50am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 50am blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 50am blood glucose urean creat na k cl hco3 angap 25am blood calcium phos mg labs on discharge 50am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 50am blood glucose urean creat na k cl hco3 angap 25am blood calcium phos mg 25am blood tsh 25am blood t4 microbiology urine culture negative imaging cxr subtle opacity within the left lung base could be secondary to atelectasis however a superimposed infectious process cannot be excluded ct head non contrast no evidence of acute large territorial infarction or hemorrhage no evidence of calvarial fracture ct c spine no evidence of acute traumatic fracture or traumatic malalignment unchanged degenerative disease as described above brief hospital course information for outpatient providers with a background history of paroxysmal svt avnrt htn hld osteoporosis and oa presenting from her assisted living facility following an episode of possible unresponsiveness with associated weakness and nausea acute issues addressed presyncope patient presented following an episode of presyncope at assisted living facility preceded by an episode of tachycardia to earlier in am with subsequent verapamil 40mg taken she was found to have negative trops and unchanged ekg from prior no signs of infection with normal white count no fever and no pyuria no dyspnea to suggest pe and no risk factors ekg did show bradycardia to and patient was initially orthostatic she was admitted to the hospital and monitored on telemetry again showing sinus bradycardia her amiodarone and amlodipine were held overnight but restarted the following morning a repeat ekg was again unchanged she worked with the team who found that she was not orthostatic and recommended home given that vital signs and labs remained stable she was discharged on her home medications with cardiology followup she was instructed to take an extra dose of amiodarone rather than verapamil should she again experience palpitations chronic issues addressed hypothyroidism continued home levothyroxine 50mcg daily tsh was elevated at but t4 normal at htn amlodipine initially held on admission restarted given stable blood pressures transitional issues patient instructed to take extra dose of amiodarone rather than verapamil should she experience another episode of avnrt discharged with cardiology follow up pending discharged with home and code status full with limited trial of life saving measures contact medications on admission the preadmission medication list is accurate and complete amiodarone mg po daily amlodipine mg po daily levothyroxine sodium mcg po daily lorazepam mg po daily prn anxiety verapamil mg po tablets daily prn palpitations aspirin mg po daily ipratropium bromide nasal two sprays in each nostril bid discharge medications amiodarone mg po daily amlodipine mg po daily aspirin mg po daily ipratropium bromide nasal two sprays in each nostril bid levothyroxine sodium mcg po daily lorazepam mg po daily prn anxiety held verapamil mg po tablets daily prn palpitations this medication was held do not restart verapamil until you speak with your cardiologist discharge disposition home with service facility discharge diagnosis primary diagnosis syncope tachycardic episode secondary diagnosis hypothyroidism paroxysmal svt avnrt 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 pleasure to be a part of your care team at you were admitted to the hospital after you experienced palpitations and then felt faint after taking verapamil we are not exactly sure why this happened it may have been because of the verapamil on top of the amiodarone we did blood tests which all looked fine you were monitored overnight and since you were feeling better were able to be discharged home we spoke with dr suggests that if this happens again you could take an extra amiodarone pill instead of the verapamil as this may prevent this from happening we have also scheduled you an appointment to see her please see below for your medications and appointments again it was very nice to meet you and we wish you the best sincerely your care team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies zosyn attending chief complaint pneumonia major surgical or invasive procedure line placement history of present illness year old with a pmhx of als with permanent trach on vent who presents with pneumonia per report patient was supposed to get a trach change today at rehab rt attempted to change it however it was difficult granulation tissue and during teh attempt the patient became apneic question of whether vent was attached and unresponsive patient was bagged and sent to there she was only responsive to painful stimuli patient was placed back on vent and cxr was performed which showed diffuse pna patient was then given ctx and azithromycin and transferred to prior to transfer labs showed trop i wbc lactate of note no bcx were collected in the ed initial vitals were t hr then on exam in the ed patient was minimally responsive diaphoretic warm to the touch bibasilar crackles labs in the ed were wbc platelets k hemolyzed cr trop ua with wbcs mod bacteria small leuks and neg nitrites initial abg was patient was seen by who increased mv with subsequent abg cxr showed r basilar opacity due to combination of layering effusion and atelectasis noting that infection is not excluded with similar retrocardiac opacity patient was given 1l ns iv vanc zosyn and 650mg apap on arrival to the micu patient is alert and responsive denies pain unable to obtain further history per son patient had recent increase in secretions past medical history als per patient diagnosed when she was hospitalized after running marathon in dm frontal lobe dementia schizoaffective d o social history family history unable to obtain physical exam admission physical exam vitals t bp p r o2 on ventilator general alert no acute distress nods head to answer questions heent sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs coarse mechanical breath sounds bilaterally cv regular rate and rhythm normal s1 s2 no murmurs rubs gallops abd soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema moves rue and b l withdraws lue to pain skin no breakdown neuro moves extremities as described above discharge physical exam vitals t bp125 p cmv vt rr fio2 peep general alert no acute distress nods head to answer questions heent sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs coarse mechanical breath sounds bilaterally cv regular rate and rhythm normal s1 s2 no murmurs rubs gallops abd soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema moves rue and b l withdraws lue to pain skin no breakdown neuro moves extremities as described above pertinent results admission labs 53pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 53pm blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 53pm blood plt 33am blood ptt 53pm blood glucose urean creat na k cl hco3 angap 53pm blood alt ast alkphos totbili 53pm blood ctropnt 33am blood ck mb ctropnt 54am blood ck mb ctropnt 00pm blood ck mb ctropnt 26am blood ck mb ctropnt 33am blood calcium phos mg 19pm blood type art po2 pco2 ph caltco2 base xs 22pm blood lactate discharge labs 28am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 28am blood ptt 28am blood glucose urean creat na k cl hco3 angap 28am blood calcium phos mg 22pm blood type art po2 pco2 ph caltco2 base xs micro pm urine urine culture preliminary escherichia coli organisms ml presumptive identification sensitivities mic expressed in mcg ml escherichia coli ampicillin r ampicillin sulbactam s cefazolin r ceftazidime s ceftriaxone r ciprofloxacin r gentamicin s meropenem s nitrofurantoin s piperacillin tazo s tobramycin s trimethoprim sulfa s am sputum source endotracheal final report gram stain final pmns and epithelial cells 100x field per 1000x field gram positive rod s per 1000x field gram negative rod s respiratory culture final moderate growth commensal respiratory flora pseudomonas aeruginosa moderate growth pseudomonas aeruginosa moderate growth second morphology gram negative rod sparse growth sensitivities mic expressed in mcg ml pseudomonas aeruginosa pseudomonas aeruginosa amikacin s cefepime s s ceftazidime s s ciprofloxacin s s gentamicin s r meropenem s s piperacillin tazo s s tobramycin s i pm swab peg site wound culture preliminary yeast sparse growth brief hospital course ms is a yo female with history of als ventilator dependence with trach and peg in place history of seizure disorder who presents with cough sob and concern for pna ventilator associate pneumonia on the day of admission patient was undergoing trach exchange but had became briefly apneic question of whether vent was attached at the time she was bagged and brought to where she was responsive to painful stimuli only patient was placed back on vent cxr was performed which showed diffuse pna she received ctx and azithromycin and transferred to icu at she was changed to vanc zosyn due to concern for vap however hospital course was complicated by ain see below this was therefore changed to vanc cefepime as the antibiotics regimen sputum cultures were positive for different strains of pseudomonas with differing sensitivities she is planned for a total of days of antibiotics from she had picc line placed for ongoing iv antibiotics tracheostomy tube was changed on from portex to portex soft seal cuff 15mm connector inner diameter outer diameter ain patient s creatinine rose to from baseline with peripheral eosinophilia and urine eosinophils fena suggestive of intrarenal concerning for ain with zosyn as suspected culprit patient s zosyn was subsequently changed to cefepime for treatment of vap and peripheral eosinophilia subsequently resolved discharge creatinine was and should be followed up after discharge as described below in the transitional issues e coli uti urine cultures on admission were notable for e coli uti which was sensitive to cefepime and will be adequately treated along with antibiotic course as above for vap nstemi troponins were increasing to at peak with ekg showing ste in precordial leads ii iii patient was seen by cardiology and received aspirin mg high dose statin and metoprolol per cardiology recommendation she was treated with hours heparin gtt she will continue on aspirin metoprolol and atorvastatin mg qhs as described below in transitional issues als patient follows with providers and at for chronic vent management dm continued home insulin and sliding scale nutrition patient was seen by nutrition who made tube feed recommendation transitional issues tracheostomy tube was changed on from portex to portex soft seal cuff 15mm connector inner diameter outer diameter patient was initiated on cefepime for vap and should complete a total nding given pseudomonas in sputum culture patient had nstemi this admission requiring hours of heparin gtt she was initiated on aspirin atorvastatin mg qhs and changed to metoprolol from home propranolol for cad please continue in the outpatient setting and consider cardiac catheterization in the future patient had likely ain in the setting of zosyn use please consider avoiding zosyn in the future please follow up creatinine to ensure normalization after zosyn discontinuation c diff pending at time of discharge given episode of diarrhea full code hcp legal guardian medications on admission the preadmission medication list is accurate and complete ferrous sulfate liquid mg po daily docusate sodium liquid mg po daily glargine units breakfast glucerna nut tx gluc intol lac free soy br nut tx glucose intolerance soy oral daily omeprazole mg po daily propranolol mg po q8h quetiapine fumarate mg po daily quetiapine fumarate mg po qhs sertraline mg po daily levetiracetam mg po bid lorazepam mg po q8h quetiapine fumarate mg po daily prn agitation guaifenesin ml po q4h discharge medications docusate sodium liquid mg po daily ferrous sulfate liquid mg po daily glargine units breakfast levetiracetam mg po bid quetiapine fumarate mg po daily quetiapine fumarate mg po qhs sertraline mg po daily aspirin mg po daily atorvastatin mg po qpm cefepime g iv q12h metoprolol tartrate mg po q6h glucerna nut tx gluc intol lac free soy br nut tx glucose intolerance soy oral daily guaifenesin ml po q4h lorazepam mg po q8h omeprazole mg po daily quetiapine fumarate mg po daily prn agitation miconazole powder appl tp bid prn irritation of peg discharge disposition extended care facility discharge diagnosis primary ventilator associated pneumonia urinary tract infection non st elevation myocardial infarction acute interstitial nephritis secondary als seizure disorder discharge condition mental status clear and coherent level of consciousness alert and interactive activity status bedbound discharge instructions dear ms you were seen at due to a pneumonia which is an infection in your lungs you were treated with antibiotics for this and you will continue this for weeks in addition you were found to have a urinary tract infection the antibiotics you are on for your pneumonia will also treat this infection finally you were found to have a mini heart attack which is most likely due to the strain on your heart while you were fighting infection you were treated with medications to help your heart and you will continue on these after your discharge please take all medications as prescribed it was a pleasure taking care of you at sincerely your care team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies zosyn attending chief complaint decreased level of consciousness major surgical or invasive procedure none history of present illness ms is a yo female with history of als ventilator dependence with tracheostomy and peg history of seizure disorder nonverbal but interactive at baseline who presents with concern for non convulsive status epilepticus after being found unresponsive ms was recently admitted to the icu from to for ventilator associated pneumonia for this prior admission she was undergoing trach exchange at her facility but had became briefly apneic question of whether vent was attached at the time she was bagged and brought to where she was responsive to painful stimuli only cxr was performed which showed diffuse pna she received ctx and azithromycin and transferred to icu at she was changed to vanc zosyn due to concern for vap hospital course was complicated by ain with creatinine rising from to and peripheral eosinophilia and fena thought to be due to zosyn sputum cultures were positive for strains of pseudomonas with variable resistance patterns her antibiotic regimen was therefore changed to vanc cefepime planned for days to end via right picc vanc was discontinued prior to discharge tracheostomy tube was changed on from portex to portex soft seal cuff 15mm connector inner diameter outer diameter she was also found to have an e coli uti treated with cefepime cardiology was consulted for nstemi as troponins were increasing to at peak with ekg showing ste in precordial leads ii iii she was treated medically with hours of heparin iv aspirin mg high dose statin and metoprolol she was clear and coherent alert and interactive and bedbound when she was discharged on on patient was at her facility found with decreased responsiveness reacting only to loud voice or sternal rub bp was noted to be fsbg she was transferred to where she was intermittently reactive to physical stimuli only occasionally looking around but mostly lying still with eyes closed at there was concern for sepsis with bp she was afebrile without hypoxemia her eyes were closed and she would not follow commands or respond to painful stimuli labs notable for negative troponin lactate wbc k creat ekg showed diffuse j point elevation pr depression in ii v3 v6 head ct showed no acute infarct intracranial hemorrhage or mass cxr showed mild persistent rll consolidation with partial obscuring of right hemidiaphragm although improved since cxr during last admission her hypotension was treated with 2l normal saline she was evaluated by neurology who recommended transfer to for monitoring for subclinical status epilepticus with eeg in the ed initial vitals t bp hr rr spo2 while in the ed her bp dropped to and subsequently improved with doses of lorazepam she was continued on full ventilator support with cmv vt rr peep fio2 same settings from rehab on exam in the ed she was noted to be following commands moving eyes nodding but unable to move extremities however she had several events with rightward eye deviation minor mouth twitching and unresponsiveness and was hypotensive to the systolic these episodes were treated with lorazepam and afterwards her bp improved but she was not following commands not answering questions not blinking to threat only grimacing to sternal rub labs demonstrated wbc pmns eosinophils hgb plt inr ptt na k bicab creat bun troponin ckmb lactate alt ast alk phos tbili alb lipase ua with moderate leuks prot wbc few bacteria she was treated with aspirin 600mg pr lorazepam 4mg iv total and loaded with keppra 1000mg also received dose of vancomycin 1000mg iv on arrival to the micu she continues to be unresponsive with leftward eye deviation initially normotensive with bp 140s subsequently decreased to 90s past medical history amyotrophic lateral sclerosis followed at dm frontal lobe dementia schizoaffective d o social history family history unable to obtain physical exam admission physical exam general unresponsive heent sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad tracheostomy tube in place no drainage or bleeding from trach site small amount of granulation tissue on inferior margin of tracheostomy stoma lungs clear to auscultation bilaterally anteriorly no wheezes rales rhonchi ventilated on cmv tv rr fio2 peep no tracheal secretions cv regular rate and rhythm normal s1 s2 no murmurs rubs gallops abd soft no reaction to deep palpation non distended bowel sounds present luq peg tube site c d i no erythema discharge or bleeding gu foley in place draining clear yellow urine ext warm well perfused pulses no clubbing cyanosis or edema msk diffuse muscle wasting in extremities bilateral temples no joint swelling or erythema skin warm and dry no defects or rashes neuro unresponsive no reaction to sternal rub pupils round 2mm sluggishly reactive eyes currently midline though on initial assessment were deviated up and to the left not moving extremities no tremor normal tone no clonus no response to painful stimuli in extremities discharge physical exam gen awake alert tracheostomy in place cv regular rate normal rhythm lungs decreased effort slight rhonchi no increased wob or respiratory distress gi soft non tender non distended g tube in place neuro flaccid upper extremities with interosseous muscle wasting moves lower extremities with purpose ext warm and well perfused pertinent results admission labs 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 00am blood ptt 00am blood glucose urean creat na k cl hco3 angap 00am blood alt ast ck cpk alkphos totbili 00am blood lipase 00am blood ck mb 00am blood ctropnt 00am blood albumin calcium phos mg 04am blood lactate troponin trend 00am blood ctropnt 02pm blood ck mb ctropnt 15pm blood ck mb ctropnt microbiology bcx pending ucx yeast sputum pm sputum source endotracheal gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s respiratory culture preliminary gram negative rod s moderate growth gram negative rod moderate growth gram negative rod moderate growth pm bronchial washings gram stain final per 1000x field polymorphonuclear leukocytes no microorganisms seen respiratory culture preliminary further incubation required to determine the presence or absence of commensal respiratory flora gram negative rod s of three colonial morphologies fungal culture preliminary no fungus isolated bcx pending bcx pending imaging cxr impression in comparison with the study there is little interval change tracheostomy tube remains in place as does the right subclavian picc line again there is opacification of the right base with obscuration of the hemidiaphragm although this could represent volume loss in the right lower lobe with associated pleural effusion in the appropriate clinical setting superimposed pneumonia would have to be considered probable atelectatic changes at the left base tte the left atrium is normal in size there is mild symmetric left ventricular hypertrophy with normal cavity size and regional global systolic function lvef the estimated cardiac index is normal 5l min m2 tissue doppler imaging suggests a normal left ventricular filling pressure pcwp 12mmhg right ventricular chamber size and free wall motion are normal the aortic valve leaflets appear structurally normal with good leaflet excursion there is no aortic valve stenosis no aortic regurgitation is seen the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be estimated there is a small circumferential pericardial effusion without echocardiographic signs of tamponade impression suboptimal image quality mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function small circumferential pericardial effusion without echocardiographic evidence for hemodynamic compromise cxr impression heart size and mediastinum are stable right picc line tip terminates at the level of superior svc heart size and mediastinum are stable tracheostomy is in unchanged position no interval development of of new consolidations is seen except for persistent right basal opacity which most likely represents a combination of atelectasis and infection there is small amount of pleural effusion bilaterally discharge labs 23am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 23am blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 23am blood ptt 23am blood glucose urean creat na k cl hco3 angap 23am blood calcium phos mg 48am blood caltibc hapto ferritn trf brief hospital course ms is a year old female with als s p trach and peg with recent admission for technical trach issues complicated by vap and type ii nstemi who presented to with decreased mental status found to have episodes of mucous plugging altered mental status during last admission had similar brief episodes of unresponsiveness that resolved without intervention now presents with multiple episodes of unresponsiveness and right then leftward eye deviation associated hypotension improved with lorazepam and documentation also indicates that she became more responsive with eyes open following simple commands prior to becoming unresponsive again per neurology consult these episodes are concerning for complex partial seizures vs non convulsive status epilepticus ultimately etiology was unclear though she has two known infections being treated with cefepime including uti and pna ct head unremarkable eeg was performed which showed no epileptiform activity she was switched to ceftazidime for antibiotic coverage out of concern for altered mental status seizures from cefepime however given the lack of correlate on eeg and the alternate explanation ie respiratory distress due to mucous plugging it is likely that her episodes both prior to and during admission were not seizures she was continued on levetiracetam 750mg po bid ecg changes and troponin elevation patient with history of recent nstemi managed medically on this admission she had fluctuating ekg changes including intermittent pr depressions and st segment changes which appear most consistent with j point elevation cardiology was consulted who recommended tte and trending of cardiac markers she was found to have preserved ef with small pericardial effusion and ekgs c w pericarditis no further treatment was recommended as the diffuse ecg changes were transient and not associated with a particular coronary distribution her troponins trended downward and she had no complaints of chest pain she was continued on asa high dose atorvastatin and metoprolol ventilator associated pneumonia diagnosed during last admission with leukocytosis fever rll infiltrate treated with cefepime for planned day course to end cxr at shows mild persistent rll infiltrate she is having minimal tracheal secretions now mild leukocytosis and no reported fevers or hypoxemia on fio2 not need to complete full day treatment acute hypoxic respiratory distress her hospital course was notable for acute hypoxemic event due to mucous plugging on the patient became acutely hypoxic down into the s following a change in position she was taken off the ventilator and bad masked given coinciding decreases in tidal volume emergent bronchoscopy was performed which revealed severe mucus plugging worse in the rll this plugging was relieved and patient s oxygen saturations came back up to high s during this episode was observed to have extensor posturing and roving eye movements however neurology evaluated clinical findings along with eeg and determined that they were not seizures during the event patient was hypertensive with sbp up to s fentanyl and versed bolus for sedation was given as well as mg iv labetalol pressures continued to be elevated throughout the afternoon and metoprolol was doubled from q6 to q6 to assist with the clearance of her secretions she was placed on the mechanical insufflator exsufflator machine which significantly assisted improved her cough she should use this every eight hours and also as needed chronic respiratory failure mechanically ventilated does not require sedation she was continued on prior vent settings cmv tv rr fio2 but with an increase in peep from to diabetes mellitus continued home lantus and insulin sliding scale htn was started on metoprolol 5mg po q6hrs would recommend continued monitoring of bp and titration of regimen at facility transitional issues please use mie every eight hours and as needed for cough please continue ceftazidime through treating ventilator associated pneumonia from previous admission please continue to monitor her bp and titrate regimen as necessary communication hcp legal guardian code full per legal guardian medications on admission the preadmission medication list is accurate and complete docusate sodium liquid mg po daily ferrous sulfate liquid mg po daily levetiracetam mg po bid quetiapine fumarate mg po daily quetiapine fumarate mg po qhs sertraline mg po daily aspirin mg po daily atorvastatin mg po qpm cefepime g iv q12h metoprolol tartrate mg po q6h glucerna nut tx gluc intol lac free soy br nut tx glucose intolerance soy oral daily guaifenesin ml po q4h lorazepam mg po q8h omeprazole mg po daily quetiapine fumarate mg po daily prn agitation miconazole powder appl tp bid prn irritation of peg glargine units breakfast insulin sc sliding scale using hum insulin polyethylene glycol g po ng daily prn constipation discharge medications aspirin mg po daily atorvastatin mg po qpm ferrous sulfate liquid mg po daily guaifenesin ml po q4h glargine units breakfast insulin sc sliding scale using hum insulin metoprolol tartrate mg po q6h polyethylene glycol g po daily prn constipation quetiapine fumarate mg po daily prn agitation sertraline mg po daily ceftazidime g iv q8h omeprazole mg po daily docusate sodium liquid mg po daily glucerna nut tx gluc intol lac free soy br nut tx glucose intolerance soy oral daily levetiracetam mg po bid miconazole powder appl tp bid prn irritation of peg quetiapine fumarate mg po qhs prn insomnia agitation lorazepam mg po q8h discharge disposition extended care facility discharge diagnosis primary diagnosis altered mental status hypoxic respiratory distress secondary diagnosies ventilator associated pneumonia ecg changes als discharge condition mental status clear and coherent level of consciousness alert and interactive activity status bedbound discharge instructions dear ms it was a pleasure taking care of you during your hospital stay at you were admitted after you were confused and less responsive than normal the neurologists evaluated you and discovered that you are not having any seizures you can continue the same keppra as before we also asked the cardiologists to see you because of your history of a recent heart attack and some changes on your ekg they felt that you were not having a new heart issue and did not recommend any new treatment during your hospital stay you had a brief episode of getting some mucous and sputum caught in your airway that caused you to lose consciousness we were able to suck the mucous out with a bronchoscopy from now we recommend that you something called the mie or cough assist to help you bring up secretions so as to prevent this from happening again we are discharging you back to your facility where they can finish your antibiotic treatment for pneumonia and provide you with the cough assist as well we wish you the best your care team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies zosyn attending chief complaint dyspnea major surgical or invasive procedure bronchoscopy history of present illness ms is a yo female with history of als ventilator dependence with tracheostomy and peg history of seizure disorder nonverbal but interactive at baseline who presents as a transfer from for hypoxemia recently admitted in the last month twice to the first was for a vap which she was treated with a day course of ceftazidime this course was supposed to have ended on on the admission she was admitted for periods of unresponsiveness and the concern for seizures neuro was consulted on that admission and ultimately did not think that she was having seizures based on eeg evaluation she was switched from cefepime to ceftazidime in case the abx selection was contributing to her mental status per report patient was at and acutely desatted down to the s with associated respiratory distress ems was called and en route her o2 sats improved with tracheal suctioning at vbg shows a ph of and cxr showed possible left lower lobe infiltrate per ed physician official read of cxr shows no acute intrathoracic process significant labs showed wbc of platelets of glucose of and tropi of she was started on vanc cefepime and brought to in the ed intial vs on fi02 patient continued on mechanical ventilation at x peep fi02 discharge settings x peep fio2 labs significant for wbc of and trop0 of she was given levaquin 750mg on arrival to the micu she is currently calm and answering yes or no questions she currently denies difficulty breathing chest pain abdominal pain she does say she has pain in her right leg and kicks her right leg every now and then she cannot localize the pain as i point to different parts of the leg past medical history amyotrophic lateral sclerosis followed at dm possible frontal lobe dementia possible schizoaffective d o social history family history unable to obtain physical exam admission physical exam vitals on fio2 general alert answers yes no questions with nods cannot verbalize heent sclera anicteric mmm oropharynx clear neck trach in place no surrounding erythema lungs upper airway rhonchorous sounds transmitted to lung fields anteriorly 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 pulses no clubbing cyanosis or edema skin no rashes neuro unable to participate in neuro exam completely due to communication able to move right move feet bilaterally unable to move arms eyes move concordantly able to shake head nod head discharge physical exam vitals hr rr on vent bp o2 sat vent settings cmv rate of volume peep fio2 producing a minute ventilation of 6l and peak pressure of general alert trached female lying in bed on vent no acute distress heent trach in place otherwise ncat rolls eyes nods head neck trach in place lungs bilateral rhoncorous breath sounds cv slight tachycardia no m r g abd soft nontender ext unable to move extremities no peripheral edema skin warm dry neuro rolls her eyes and nods her head to communicate no motor strength in extremities pertinent results admission labs 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood ptt 00am blood glucose urean creat na k cl hco3 angap 00am blood ctropnt 09am blood lactate 28am blood type central ve po2 pco2 ph caltco2 base xs cxr small areas of residual consolidation or atelectasis persist at the lung bases not enough to explain respiratory insufficiency upper lungs are clear heart size top normal no pleural abnormality tracheostomy tube midline discharge labs 43am blood hgb hct 04am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 04am blood plt 04am blood ptt 04am blood glucose urean creat na k cl hco3 angap 21am blood glucose urean creat na k cl hco3 angap 04am blood calcium phos mg 08am blood temp rates tidal v peep fio2 po2 pco2 ph caltco2 base xs intubat intubated 08am blood lactate pm bronchial washings gram stain final per 1000x field polymorphonuclear leukocytes no microorganisms seen respiratory culture final commensal respiratory flora absent acinetobacter baumannii complex organisms ml identification and sensitivities performed on culture sputum from stenotrophomonas maltophilia organisms ml sensitivities performed on culture sputum pseudomonas aeruginosa organisms ml sensitivities mic expressed in mcg ml pseudomonas aeruginosa cefepime s ceftazidime s ciprofloxacin s gentamicin s meropenem s piperacillin tazo s tobramycin s fungal culture preliminary no fungus isolated brief hospital course ms is a yo female with history of als ventilator dependence with tracheostomy and peg history of seizure disorder nonverbal but interactive at baseline who presents as a transfer from for hypoxemia respiratory failure patient ventilator dependent from als with chronic trach desatted acutely at nursing facility and improved rapidly with suctioning etiology likely mucus plugging from impaired secretion clearance due to als no infiltrate on imaging to suggest pna was not treated with antibiotics in icu mie cough assist device used q8hours effectively here bronchoscopy did not show any residual plugging patient is being discharged to a facility that has respiratory therapy on site to prevent this type of occurrence from happening again g tube placement patient presented with foley tubing in g tube stoma that was being used as g tube patient underwent guided placement of appropriate g j tube that functioned well following placement troponinemia patient with trop of less than last trop of on previous admission which was not thought to represent acs but rather pericarditis given pr elevation and small effusion seen on echo denied any chest pain and ekg showed st changes consistent with prior likely related to lvh seizure ppx patient admitted for episodes of ams with concern for seizure last admission although she ultimately was thought not to be having seizures given her risk she was continued on keppra and this was continued on this admission iddm continued lantus regular insulin agitation shizoaffective disorder continued home seroquel and setraline transitional issues please use mie as frequently as possible at least q6h to prevent mucus plugging please note ventilator settings noted in discharge physical exam please note bronchoscopy showed no significant mucous plugging see detailed culture results from bronchoscopy in results section communication hcp legal guardian code full per legal guardian medications on admission the preadmission medication list is accurate and complete aspirin mg po daily atorvastatin mg po qpm ferrous sulfate liquid mg po daily guaifenesin ml po q4h glargine units breakfast insulin sc sliding scale using reg insulin metoprolol tartrate mg po q6h polyethylene glycol g po daily prn constipation quetiapine fumarate mg po daily prn agitation sertraline mg po daily omeprazole mg po daily docusate sodium mg po bid levetiracetam mg po bid quetiapine fumarate mg po qhs prn insomnia agitation lorazepam mg po q8h acetaminophen mg po q6h discharge medications acetaminophen mg po q6h aspirin mg po daily atorvastatin mg po qpm ferrous sulfate liquid mg po daily guaifenesin ml po q4h glargine units breakfast insulin sc sliding scale using reg insulin levetiracetam mg po bid lorazepam mg po q8h omeprazole mg po daily polyethylene glycol g po daily prn constipation quetiapine fumarate mg po daily prn agitation quetiapine fumarate mg po qhs prn insomnia agitation sertraline mg po daily metoprolol succinate xl mg po daily docusate sodium mg po bid discharge disposition extended care facility discharge diagnosis respiratory failure als discharge condition mental status clear and coherent level of consciousness alert and interactive activity status bedbound discharge instructions dear ms you were admitted because you were having trouble breathing we believe this is because you had some mucus in your lungs you improved when we suctioned this out you will be going to a facility with respiratory therapists to hopefully prevent this from happening again sincerely your team followup instructions

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 headache major surgical or invasive procedure cesarean delivery blood transfusions history of present illness pt presented with elevated bp and headache at 37w6d in the office she went to l d for evaluation past medical history her medical history is significant for hypertension hyperlipidemia seizure disorder secondary to avm in the brain with her first seizure years ago and her last seizure history of migraine headaches osteoarthritis of bilateral knee joints right greater than left chronic low back pain vitamin d deficiency hepatic steatosis by ultrasound study her surgical history includes right parietal occipital avm resection placement of a laparoscopic adjustable gastric band removal of adjustable gastric band secondary to prolapse social history family history she works as a at and lives with her wife who is a physical exam on admission 41bp 46bp 01bp 16bp 21bp gen a o comfortable pulm normal work of breathing abd soft gravid nontender efw med large cephalic by ext no calf tenderness on discharge vitals hr data last updated temp tm bp hr rr o2 sat gen nad a ox3 cardiopulm no respiratory distress abd soft ntnd fundus firm nontender below umbilicus incision c d i no erythema or purulent drainage ext no calf tenderness pertinent results 05am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 01pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 10am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 20pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 17am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 52pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 39pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 53pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 10am creat 39pm blood creat 53pm blood creat 30am blood alt ast 53pm blood alt ast cxr heart size is enlarged but this might represent physiologic pregnancy increased cardiovascular volume status although true enlargement of the cardiac silhouette due to pathological causes is a possibility correlation with echocardiography is recommended left retrocardiac opacity might represent atelectasis but infectious process is a possibility no pulmonary edema no appreciable pleural effusion no pneumothorax ct large anterior pelvic hematoma measures x x cm moderate size hemoperitoneum no active hemorrhage is identified cta impression large lower anterior uterine segment bladder flap hematoma appears fairly similar in size to slightly contracted compared to prior imaging no active extravasation of contrast arterial bleed small subcutaneous hematoma is in the lower anterior abdominal pelvic wall brief hospital course ms is a year old g1p1 who underwent a primary low transverse cesarean section on delivery by cesarean was chosen due to patient preference because of her history of epilepsy and prior surgery for arteriovenous malformation delivery was recommended as patient had developed a headache overnight refractory to medications she was thus diagnosed with chronic htn with superimposed severe pre eclampsia severe by ha her post operative course was complicated by acute blood loss anemia secondary to a large pelvic hematoma regarding her chronic hypertension with superimposed pre eclampsia her headache improved after delivery she has normal labs and a urine p c that was she was started on magnesium post partum which was kept for hours her magnesium was stopped early given new onset oliguria a mag level was normal at regarding her acute blood loss anemia patient initially started feeling symptomatics with bps in the on she was noted to be oliguric at 30cc hr and received a 250cc bolus given new shortness of breath patient underwent a chest xray which returned consistent with atelectasis her hematocrit was trended and she was noted to have a significant decrease in her hematocrit from pre operatively to on decision was made to transfuse units of packed rbcs and obtain imaging a ct abdomen and pelvis was notable for a cm hematoma anterior to the lower uterine segment moderate hemoperitoneum and no evidence of active bleed given stability embolization deferred on patient required an additional units of packed rbcs she had an inappropriate rise in her hct at from and therefore was transfused another units for a total of units during her hospital stay given need for multiple blood transfusions repeat imaging with cta was obtained showing interval decrease in the hematoma and no area of active bleeding of note given her acute blood loss anemia patient suffered an which resolved by by patient was in stable condition with stable vitals and stable labs she met all her post operative milestones and was discharged to home with close follow up medications on admission pnv lamictal mg folic acid fioricet prn celexa 20mg discharge medications acetaminophen mg po q6h citalopram mg po daily ibuprofen mg po q6h prn pain mild rx ibuprofen mg tablet s by mouth every six hours disp tablet refills oxycodone immediate release mg po q4h prn pain rx oxycodone mg tablet s by mouth every six hours disp tablet refills lamotrigine mg po qpm lamotrigine mg po qam discharge disposition home discharge diagnosis cesarean delivery preeclampsia post operative bleeding anemia blood transfusions discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions routine postpartum instructions followup instructions

name unit no admission date discharge date date of birth sex m service orthopaedics allergies no known allergies adverse drug reactions attending chief complaint left posterior wall acetabular fracture status post mvc major surgical or invasive procedure no surgeries performed history of present illness reason for consult status post mvc with left posterior wall acetabular fracture hpi male w hx hepatitis c substance abuse adhd depression presents status post mvc in which he was the restrained front seat passenger he was brought to an outside hospital where imaging showed a left acetabular fracture and he was transferred here he does note predominantly left hip pain as well as some bumps and bruises elsewhere pain is predominantly on the left side of his body he notes left leg pain but no numbness or tingling denies any chest pain trouble breathing past medical history arthralgia back pain bipolar disorder exudative tonsillitis hepatitis c heroin abuse social history pack day smoker endorses some alcohol use though he is vague sixpacks per week has a history of heroin use as well as cocaine use notes he relapsed with cocaine a week ago he is on suboxone with his clinic at in physical exam general well appearing male in no acute distress right upper extremity skin intact no deformity soft nontender forearm and wrist he has full painless range of motion at the shoulder elbow wrist digits motor intact to epl fpl io silt axillary radial median ulnar nerve distributions radial pulse wwp left upper extremity skin intact no deformity some scattered abrasions with one over the clavicle he does note tenderness to palpation at the distal radius though he has good range of motion there soft non tender arm fires epl fpl dio silt axillary radial median ulnar nerve distributions radial pulse wwp right lower extremity skin intact no deformity edema ecchymosis erythema induration soft non tender thigh and leg full painless rom at hip knee and ankle fires silt s s sp dp t distributions pulses wwp right lower extremity skin intact no deformity edema ecchymosis erythema induration soft tenderness to palpation at tibia and ankle fires able to flex and extend at the knee silt s s sp dp t distributions pulses wwp brief hospital course the patient presented to the emergency department and was evaluated by the orthopedic surgery team the patient was found to have a left posterior wall acetabular fracture and was admitted to the orthopedic surgery service the patient was treated nonoperatively and worked with physical therapy who determined that discharge to home with home was appropriate the patient was given anticoagulation per routine and the patient s home medications were continued throughout this hospitalization on the night of patient was found apneic satting in the s and unarousable a code blue was called and multiple doses of narcan were given the patient was transferred to the tsicu utox upon arrival was floridly positive for multiple substances found to have drugs in rectum per tsicu staff that were believed to have been brought in by his friends he was placed on a narcan drip he stayed in the tsicu until largely for monitoring purposes he was weaned from his narcan drip and seen by addiction psych and chronic pain chronic pain suggested the patient go back onto his home regimen of suboxone and klonopin addiction psych provided final recommendations which included mr is a year old male with opiate use disorder on buprenorphine maintenance for months recent relapse on opiates which he attributes to hanging with the wrong he was inducted back on buprenorphine while hospitalized he is ready to home today attempted to reach psych np at she confirmed he is a patient there and missed his last appointment with her plan to use remaining buprenorphine he has at home to get to his next appt on encouraged to attend his weekly therapy session and add recovery meetings that have helped him stabilize in the past he is not interested in iop or php at this time at the time of discharge the patient s pain was well controlled without additional narcotic pain medications other than his home burprenorphine the patient was voiding moving bowels spontaneously the patient is touchdown weightbearing in the left lower extremity and will be discharged on lovenox for dvt prophylaxis the patient will follow up with dr routine a thorough discussion was had with the patient regarding the diagnosis and expected post discharge course including reasons to call the office or return to the hospital and all questions were answered the patient was also given written instructions concerning precautionary instructions and the appropriate follow up care the patient expressed readiness for discharge medications on admission amphetamine dextroamphetamine buprenorphine bupropion sustained release citalopram clonazepam clonidine lamotrigine trazodone discharge medications acetaminophen mg po q6h enoxaparin sodium mg sc qhs start today first dose next routine administration time rx enoxaparin mg ml mg subcutaneously nightly disp syringe refills lidocaine patch ptch td qam rx lidocaine apple one patch to area of pain once daily prn disp patch refills nicotine patch mg day td daily albuterol inhaler puff ih q6h prn wheezing amphetamine dextroamphetamine mg po bid buprenorphine mg sl daily bupropion sustained release mg po bid citalopram mg po daily clonazepam mg po bid clonidine mg po bid lamotrigine mg po bid trazodone mg po qhs prn insomnia discharge disposition home with service facility discharge diagnosis left posterior wall acetabular fracture discharge condition avss nad a ox3 lle no pain with log roll or gentle hip rom fires silt throughout wwp discharge instructions instructions after orthopaedic surgery you were in the hospital for orthopedic surgery it is normal to feel tired or washed out after surgery and this feeling should improve over the first few days to week resume your regular activities as tolerated but please follow your weight bearing precautions strictly at all times activity and weight bearing tdwb lle medications take tylenol every hours around the clock this is an over the counter medication you should continue to take your suboxone and other medications as prescribed by column health please follow up with them for ongoing prescriptions anticoagulation please take lovenox daily for weeks physical therapy tdwb lle treatments frequency no wounds or specific wound care instructions followup instructions

name unit no admission date discharge date date of birth sex f service neurosurgery allergies no known allergies adverse drug reactions attending chief complaint headache nausea vomiting major surgical or invasive procedure coil embolization of right posterior communicating artery aneurysm history of present illness is a female who presents as transfer from with headache and nausea found to have sah patient reports that she was in her normal state of health on the morning of when she developed sudden onset headache while drinking her morning coffee she reports nausea and vomiting ems was called and she was brought to for evaluation revealed sah of note she was hypertensive with sbp up to at osh she was transferred to for neurosurgical evaluation history obtained from patient time of headache onset 8am on past medical history denies social history family history no family hx of aneurysm physical exam on admission t hr bp rr ra gen wd wn comfortable nad heent normocephalic nontraumatic neck supple extrem warm and well perfused no edema neuro mental status awake and alert cooperative with exam normal affect orientation oriented to person place and date language speech fluent with good comprehension no dysarthria or paraphasic errors cranial nerves i not tested ii pupils equally round and reactive to light 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 finger rub bilaterally ix x palatal elevation symmetrical xi sternocleidomastoid and trapezius normal bilaterally xii tongue midline without fasciculations motor normal bulk and tone bilaterally no abnormal movements tremors strength full power throughout no pronator drift sensation intact to light touch at discharge opens eyes x spontaneous to voice to noxious orientation x person x place x time follows commands simple x complex none pupils 2mm bilat eom x full restricted face symmetric x yes notongue midline x yes no pronator drift x yes no speech fluent x yes no comprehension intact x yes no motor trapdeltoidbiceptricepgrip ipquadhamatehlgast x sensation intact to light touch angio groin site x soft no hematoma x palpable pulses pertinent results please refer to omr for relevant imaging and lab results brief hospital course pt presented to ed with found to have a right posterior communicating artery aneurysm on cta and was taken urgently for embolization post procedure she was admitted to the icu for close observation on she was transferred to the neuroscience intermediate unit for ongoing care and management subarachnoid hemorrhage the patient was monitored for vasospasm she was started on nimodipine and her fluid status was kept even to decrease the risk for vasospasm cta on was concerning for possible spasm she remained neurologically stable iv fluid boluses were discontinued and the patient remained euvolemic on she continued to do well and was deemed safe and ready for discharge home headache prophylaxis the patient was treated with a dexamethasone taper for management of headaches she was additionally covered with oral analgesics and her pain was well controlled medications on admission none discharge medications acetaminophen mg po q6h prn pain mild aspirin mg po daily bisacodyl mg po pr daily prn constipation docusate sodium mg po bid nimodipine mg po q4h end rx nimodipine mg capsule s by mouth every hours disp capsule refills oxycodone immediate release mg po q6h prn pain moderate rx oxycodone mg tablet s by mouth every hours as needed disp tablet refills senna mg po bid prn constipation discharge disposition home discharge diagnosis subarachnoid hemorrhage right posterior communicating artery aneurysm discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions discharge instructions aneurysmal subarachnoid hemorrhage surgery procedures you had a cerebral angiogram to embolize the aneurysm you may experience some mild tenderness and bruising at the puncture site groin activity we recommend that you avoid heavy lifting running climbing or other strenuous exercise until your follow up appointment you make take leisurely walks and slowly increase your activity at your own pace try to do too much all at once you make take a shower no driving while taking any narcotic or sedating medication if you experienced a seizure while admitted you must refrain from driving medications resume your normal medications and begin new medications as directed you have been instructed by your doctor to take one a day if so do not take any other products that have aspirin in them if you are unsure of what products contain aspirin as your pharmacist or call our office please do not take any other blood thinning medication plavix coumadin until cleared by the neurosurgeon you have been discharged on a medication called nimodipine this medication is used to help prevent cerebral vasospasm narrowing of blood vessels in the brain you may use acetaminophen tylenol for minor discomfort if you are not otherwise restricted from taking this medication what you experience mild to moderate headaches that last several days to a few weeks difficulty with short term memory fatigue is very normal constipation is common be sure to drink plenty of fluids and eat a high fiber diet if you are taking narcotics prescription pain medications try an over the counter stool softener when to call your doctor at for severe pain swelling redness or drainage from the incision site or puncture site fever greater than degrees fahrenheit constipation blood in your stool or urine nausea and or vomiting extreme sleepiness and not being able to stay awake severe headaches not relieved by pain relievers seizures any new problems with your vision or ability to speak weakness or changes in sensation in your face arms or leg call and go to the nearest emergency room if you experience any of the following sudden numbness or weakness in the face arm or leg sudden confusion or trouble speaking or understanding sudden trouble walking dizziness or loss of balance or coordination sudden severe headaches with no known reason followup instructions

name unit no admission date discharge date date of birth sex f service neurosurgery allergies no known allergies adverse drug reactions attending chief complaint groin pain major surgical or invasive procedure pipeline embolization of right ica aneurysm history of present illness in female well known to neurosurgery for ruptured aneurysm she initially presented with a terrible headache in and underwent emergent coil embolization of a ruptured right posterior communicating artery aneurysm on at the time there was ii resolved she presented for a follow up angiogram on that showed that there was some residual at the neck similar to the appearance at the end of the case she is felt to be a candidate for pipeline embolization we talked about the risks and benefits of that procedure and the ability to not need to follow the aneurysm once it was proven gone follow up after pipeline she is interested in proceeding past medical history secondary to right pcomm aneurysm rupture social history family history no family hx of aneurysm physical exam on discharge x nad perrla cn ii xii intact ls clear rrr abdomen soft ntnd bue and ble no drift groin site soft without hematoma peripheral pulses intact pertinent results please refer to for pertinent imaging and lab results brief hospital course is a year old female with history of secondary to right pcomm aneurysm rupture in s p emergent coil embolization recent angiogram demonstrates residual filling of aneurysm and patient returns now for elective pipeline embolization of the right pcomm artery aneurysm right pcomm aneurysm patient presented to pre op area was assessed by anesthesia and taken to the or on for right pipeline embolization of pcomm aneurysm patient tolerate the procedure well please refer to formal op report in omr for further intra operative details patient was successfully extubated and transferred to the pacu for post op care she remained stable overnight due to her right groin pain us was done which was negative for pseudoaneurysm of hematoma patient was discharged home on medications on admission clopidogrel mg tablet tab po daily aspirin mg tablet tab po daily discharge medications acetaminophen mg po q6h prn fever or pain docusate sodium mg po bid senna mg po qhs aspirin mg po daily rx aspirin mg one tablet s by mouth once a day disp tablet refills clopidogrel mg po daily rx clopidogrel mg one tablet s by mouth once a day disp tablet refills discharge disposition home discharge diagnosis residual right pcomm aneurysm discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions discharge instructions dr activity may gradually return to your normal activities but we recommend take it easy for the next hours to avoid bleeding from your groin heavy lifting running climbing or other strenuous exercise should be avoided for ten days this is to prevent bleeding from your groin make take leisurely walks and slowly increase your activity at your own pace try to do too much all at once do not go swimming or submerge yourself in water for five days after your procedure make take a shower medications resume your normal medications and begin new medications as directed may be instructed by your doctor to take one a day and or plavix if so do not take any other products that have aspirin in them if are unsure of what products contain aspirin as your pharmacist or call our office may use acetaminophen tylenol for minor discomfort if are not otherwise restricted from taking this medication if take metformin glucophage may start it again three days after your procedure care of the puncture site will have a small bandage over the site remove the bandage in hours by soaking it with water and gently peeling it off keep the site clean with soap and water and dry it carefully may use a band aid if wish what experience mild tenderness and bruising at the puncture site groin soreness in your arms from the intravenous lines mild to moderate headaches that last several days to a few weeks fatigue is very normal constipation is common be sure to drink plenty of fluids and eat a high fiber diet if are taking narcotics prescription pain medications try an over the counter stool softener when to call your doctor at for severe pain swelling redness or drainage from the puncture site fever greater than degrees fahrenheit constipation blood in your stool or urine nausea and or vomiting extreme sleepiness and not being able to stay awake severe headaches not relieved by pain relievers seizures any new problems with your vision or ability to speak weakness or changes in sensation in your face arms or leg followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies latex augmentin attending chief complaint petechiae purpura lower extremity swelling ankle tenderness predominantly r side major surgical or invasive procedure skin biopsy history of present illness in brief dr is a yo general pediatrician at with a complicated ophtho hx spontaneous retinal tear several years ago p w bilateral lower extremity palpable purpura transaminitis and microscopic hematuria beginning days after starting augmentin for suspected sialolithiasis of the r submandibular gland on pt initially presented to urgent care with day of painful swelling below the right of midline mandible of the jaw she was rxed empirically with augmentin 875mg po bid x 10d on she followed up w ent who suspected sialolithiasis on their exam r smg enlarged ttp mobile and ordered ct neck but pt never actually had imaging done on she presented to urgent care again w improvement in r submandibular pain and swelling but had low grade fever and a painful purpuric rash most prominently on the r shin during this time she did not have any chills night sweats weight loss shortness of breath chest discomfort abdominal pain diarrhea headaches vision changes or changes to her urine per recs of on call rheumatology augmentin was stopped and she was transferred to ed for further evaluation in the ed her initial vitals were hr bp rr ra her exam was notable for palpable purpura with areas of petechiae and confluence on rle extending from the r ankle to r knee lle less involved no rash on abdomen back buttocks face head neck extremities left ankle equisitely tender labs notable for wbc polys inr bun scr rbcs in urine ast alt alkphos ldh fibrinogen d dimer lactate imaging notable for cxr no acute cardiopulmonary process pt given po doxycycline hyclate mg iv ketorolac mg vitals prior to transfer ra on the floor pt reported pain and swelling of her r l legs she felt that the r ankle was particular tender with the greatest pain located just inferior to the right lateral malleolus her skin findings were somewhat painful as well she was otherwise comfortable and well appearing of note patient denied any recent travel hikes in the woods sexual contacts has been many years drug use or animal exposures given her job as she does have sick contacts her routine cancer screening is up to date her family history is notable in that her mother had syndrome and breast cancer and her father had pancreatic cancer otherwise there is no other family history of autoimmune disease or cancer review of systems low grade fever dry eyes dry cough the cough is long standing and tends to flare up during this time of year past medical history retinal tear r eye gerd asthma allergies social history family history father htn dm glaucoma pancreatic cancer mother cancer died from cvd twin sister healthy physical admission physical exam vital signs ra general alert oriented no acute distress heent right ptosis chronic right eye minimally reactive oral mucosa notable for bilateral erythematous lesions in the area of the opening of the parotid duct neck fullness in the right submandibular area lymph nodes no cervical suplraclavicular axillary inguinal lymphadenopathy cv regular rate and rhythm normal s1 s2 no murmurs rubs gallops lungs clear to auscultation bilaterally no wheezes rales rhonchi abdomen soft non tender non distended skin right leg more swollen than left right leg with confluent palpable purpura with scattered petechiae tracking up inner thihg left leg with tender raised nodules and petechiae images in omr ext warm well perfused pulses neuro cnii xii intact strength upper lower extremities grossly normal sensation reflexes bilaterally gait deferred discharge physical exam vitals po r sitting ra general alert oriented no acute distress heent right ptosis chronic there are erythematous lesions near the entrances of the parotid ducts bilaterally neck fullness in the right submandibular area lymph nodes no cervical lymphadenopathy cv rrr normal s1 s2 no murmurs rubs gallops lungs ctab abdomen soft non tender non distended skin r leg with confluent palpable purpura with scattered petechiae tracking up inner thigh r leg more swollen than left r ankle swollen and tender left leg with tender raised nodules and petechiae l thigh with new streaks of petchiae and purpura extending to buttocks ext warm well perfused neuro grossly normal motor function and sensation pertinent results admission labs 30pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30pm blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 30pm blood hypochr normal anisocy normal poiklo occasional macrocy normal microcy normal polychr normal envelop occasional 30pm blood ptt 30pm blood 30pm blood glucose urean creat na k cl hco3 angap 30pm blood alt ast ld ldh ck cpk alkphos totbili 30pm blood ctropnt 30pm blood albumin 30pm blood d dimer 30pm blood hbsag negative hbsab positive hbcab negative 30pm blood anca negative b 30pm blood crp 30pm blood igg iga igm 30pm blood c3 c4 30pm blood hcv ab negative 36pm blood lactate 30pm blood sed rate test discharge labs 40am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 40am blood glucose urean creat na k cl hco3 angap 40am blood alt ast ld ldh alkphos totbili 40am blood calcium phos mg other pertinent labs 20pm blood cryoglb pnd 30pm blood d dimer 30pm blood hbsag negative hbsab positive hbcab negative 30pm blood anca negative b 30pm blood crp 20pm blood pep no specifi freelam fr k l 30pm blood igg iga igm 30pm blood c3 c4 30pm blood hcv ab negative 30pm blood sed rate test 30pm blood ro microbiology urine culture negative 2x blood cultures pending imaging chest frontal pa and lateral views x ray comparison none findings no focal consolidation is seen there is no pleural effusion or pneumothorax the cardiac and mediastinal silhouettes are unremarkable no pulmonary edema is seen impression no acute cardiopulmonary process if clinical concern persists for small pulmonary nodules chest ct is more sensitive brief hospital course dr is a year old woman w h o spontaneous retinal tear admitted w palpable purpura in bilateral lower extremities and right ankle swelling in the setting of augmentin which she started for suspected sialolithiasis and submandibular gland infection found to have leukocytoclastic vasculitis and improved with cessation of augmentin and initiation of prednisone active issues leukocytoclastic vasculitis lcv patient presented with palpable purpura of the bilateral lower extremities with right ankle swelling labs notable for transaminitis and microscopic hematuria seen by dermatology and rheumatology and underwent skin biopsy with pathology confirming leukocytoclastic vasculitis lcv the recent history of augmentin usage and infection is consistent with lcv her augmentin was held and she was started on prednisone to which she improved at the time of discharge she was having resolving transaminitis resolved microscopic hematuria and improved ankle right pain and lower right leg swelling although still noticing new petechiae which can be seen in lcv despite withdrawal of offending stimulus continued on prednisone 20mg daily on discharge with a plan to decrease to 15mg daily after one week and follow up with rheumatology and dermatology right submandibular gland swelling patient initially presented to an outside urgent care clinic on with right submandibular gland swelling and tenderness started empirically on augmentin and initially thought to have sialolithiasis with concurrent infection which is plausible given that patient s symptoms improved with augmentin therapy however given the family history of and the patient s joint symptoms on her admission to there was concern that her initial jaw tenderness could have been part of a broader rheumatological process and a rheumatological workup was done at the time of discharge her workup was notable for negative negative anca and negative sjogren antibodies and the patient s right submandibular gland swelling and tenderness had improved significantly and she was otherwise stable she will need to follow up with ent after discharge and consider possible ct scan chronic issues retinal tear continued home eye drops transitional issues patient should have sutures removed on from her biopsy site if pruritus develops dermatology recommended triamcinolone ointment bid to affected areas use up to two weeks per month patient s malignancy screening should be clarified to ensure that she is up to date pt needs to follow up with ent for management of the right submandibular gland swelling consider outpatient ct neck per ent pt needs to continue prednisone 20mg daily and then decrease to 15mg daily after one week until follow up with outpatient rheumatology augmentin added to the allergy list it is unclear whether patient can be exposed to penicillins in the future can consider outpatient allergy referral pt needs to have repeat lfts as an outpatient consider further workup if not resolved contact sister hcp code status full presumed medications on admission the preadmission medication list is accurate and complete prednisolone acetate ophth susp drop right eye times per day alternating with times per day dorzolamide ophth soln drop right eye tid brimonidine ophthalmic bid fexofenadine mg po daily prn allergies albuterol inhaler puff ih q6h prn shortness of breath discharge medications prednisone mg po daily take 20mg daily for days then decrease to 15mg daily rx prednisone mg tablet s by mouth daily disp tablet refills albuterol inhaler puff ih q6h prn shortness of breath brimonidine ophthalmic bid dorzolamide ophth soln drop right eye tid fexofenadine mg po daily prn allergies prednisolone acetate ophth susp drop right eye times per day alternating with times per day discharge disposition home discharge diagnosis primary leukocytoclastic vasculitis secondary to augmentin usage and infection secondary sialolithiasis 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 dr was a pleasure taking care of you during your hospital stay at you were hospitalized for the onset of petechiae purpura lower leg swelling and ankle tenderness predominantly on your right lower leg in the setting of days of augmentin usage upon admission you were found to have signs of mild injury to your liver and kidney you were found to have a leukocytoclastic vasculitis and your symptoms managed with cessation of augmentin and initiation of prednisone to which you responded well on discharge it is important for you to continue applying vaseline to your biopsy site with a change in the bandaid daily continue to wrap the leg and elevate it to facilitate resolution of the edema if the rash worsens or becomes more bothersome please page dermatology at during business hours or call and request pager after hours please continue to take your home medications as prescribed in particular you should take mg of prednisone daily for week from discharge after which you should take mg of prednisone daily until you have your follow up rheumatology appointment for management of your pain ibuprofen or tylenol are acceptable but do not exceed g tylenol daily given your recent transaminitis take care your team followup instructions

name unit no admission date discharge date date of birth sex f service cardiothoracic allergies sulfa sulfonamide antibiotics cipro attending chief complaint dyspnea on exertion major surgical or invasive procedure mitral valve repair with a resection of the middle scallop of the posterior leaflet p2 and a mitral valve annuloplasty with a annuloplasty band history of present illness ms is an year old woman with a history of chronic obstructive pulmonary disease hyperlipidemia mitral valve prolapse and moderate mitral regurgitation for full details please see full h p by on briefly she noted onset of dyspnea on exertion an echocardiogram on which demonstrated bi leaflet mitral prolapse and moderate mitral regurgitation she was underwent a transesophageal echocardiogram which revealed bileaflet mitral valve prolapse with partial flail of the p2 and p3 scallops and moderate mitral regurgitation she was referred to dr surgical evaluation given her history of copd he recommended cardiac catheterization and pulmonary function tests to further evaluate the cardiac catheterization showed no significant coronary artery disease pulmonary function tests demonstrated mildly decreased diffusing capacity she returns for surgical planning since her last visit she has had no significant change in her medical history of her symptoms she continues to have dyspnea on exertion with minimal exertion she has intermitted lower extremity edema and takes diuretics as needed she denied syncope dizziness lightheadedness shortness of breath at rest chest pain palpitations orthopnea or paroxysmal nocturnal dyspnea past medical history chronic bronchitis chronic obstructive pulmonary disease degenerative joint disease hyperlipidemia mitral regurgitation mitral valve prolapse right foot hammer toe bilateral knee replacement bilateral thumb surgery appendectomy partial hysterectomy bladder sling surgery social history family history mother died of stroke father died of heart disease physical exam preoperative examination vital signs sheet entries for bp hr o2 sat rr pain score height weight 146lb general pleasant woman wdwn nad skin warm dry intact heent ncat perrla eomi teeth in fair repair neck supple full rom chest lungs clear bilaterally heart regular rate and rhythm with mid systolic click abdomen normal bs soft non distended non tender extremities warm well perfused trace edema varicosities none neuro grossly intact pulses dp right present left present right present left present radial right present left present carotid bruit none appreciated discharge examination vital signs i o hr data last updated temp tm bp hr rr o2 sat o2 delivery ra wt lb kg fluid balance last updated last hours total cumulative 110ml in total 360ml po amt 360ml out total 250ml urine amt 250ml last hours total cumulative 70ml in total 820ml po amt 820ml out total 750ml urine amt 750ml physical examination general nad x neurological a o x3 x non focal x heent peerl cardiovascular rrr x irregular murmur rub respiratory cta no resp distress decreased at bases with bibasilar crackles gi abdomen bowel sounds present x soft x nd x nt x incontinent of stool this am extremities right upper extremity warm x edema tr left upper extremity warm x edema tr right lower extremity warm x edema left lower extremity warm x edema pulses dp right left right left radial right left skin wounds dry x intact x sternal cdi x no erythema or drainage x sternum stable x prevena pertinent results echocardiogram aorta ascending cm cm findings left atrium mild no spontaneous echo contrast in the body of the no spontaneous echo contrast is seen in the right atrium interatrial septum normal interatrial septum left ventricle normal lv wall thickness normal lv cavity size normal regional lv systolic function overall normal lvef no lv mass thrombus right ventricle normal rv free wall thickness normal rv chamber size normal rv systolic function aorta normal ascending aorta diameter aortic valve no as mild ar mitral valve normal mitral valve supporting structures no ms mr valve mild to moderate tr pericardium no pericardial effusion conclusions the left atrium is mildly dilated no spontaneous echo contrast is seen in the body of the left atrium no spontaneous echo contrast is seen in the left atrial appendage left ventricular wall thicknesses are normal the left ventricular cavity size is normal regional left ventricular wall motion is normal overall left ventricular systolic function is normal lvef no masses or thrombi are seen in the left ventricle the right ventricular free wall thickness is normal right ventricular chamber size is normal with normal free wall contractility there is no aortic valve stenosis mild aortic regurgitation is seen moderate mitral regurgitation is seen tthere is p2 prolapse the sbvalvular apparatus is normal the re sre no predictors there is no pericardial effusion post bypass the biventricular fuinctionis preserved the mitral valve shows trace mitral regurgitation the rest of the exam is unchanged the thoracic aorta is intact 47am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 09am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 47am blood 09am blood 55am blood ptt 47am blood glucose urean creat na k cl hco3 angap 09am blood glucose urean creat na k cl hco3 angap 55am blood glucose urean creat na k cl hco3 angap brief hospital course presented same day admission and was brought to the operating room underwent mitral valve repair please see operative note for further details of note she was transfused with blood in operating room for blood loss post operatively she was taken to the intensive care unit for management within a few hours she was weaned from sedation awoke neurologically intact and extubated without complications she was weaned off vasoactive medications her hematocrit and platelets were monitored and she did not require any further trasnfusions on post operative day one she was started on betablocker and diuretic she was ready to transition to the floor but remained awaiting bed availability she continued to progress chest tubes were removed and noted for apical pneumothorax that progressively resolved post operative day three she developed atrial fibrillation and was treated with amiodarone and betablockers she developed hypotension with the atrial fibrillation requiring neosynephrine that was weaned off the am of post operative day four her epicardial wires were removed per protocol she continued to intermittent atrial fibrillation and betablocker was adjusted and she was initiated on coumadin for anticoagulation she worked with physical therapy in strength and mobility with recommendation for rehab additionally she was noted for leukocytosis that progressively resolved with white blood cell count normal at time of discharge she was given additional lasix for lower extremity edema and pleural effusion oxygen saturation was on room air she was therapeutic on coumadin for inr goal at the time of discharge patient was ambulating with assistance she was tolerating an oral diet with increasing appetite and incision was healing well she is to have coumadin follow up to be arranged upon discharge from rehab she was transferred to rehab on pod in stable condition stop medications on admission the preadmission medication list is accurate and complete symbicort budesonide formoterol mcg actuation inhalation bid diclofenac sodium topical qid prn hydrochlorothiazide mg po daily prn edema ipratropium bromide mdi puff ih tid naproxen mg po q12h prn pain mild simvastatin mg po qpm ascorbic acid mg po bid coricidin hbp cough and cold chlorpheniramine dextromethorp mg oral daily prn vitamin d unit po daily cyanocobalamin mcg po daily multivitamins tab po daily fish oil omega mg po bid discharge medications acetaminophen mg po q6h prn pain mild fever albuterol neb soln neb ih q2h prn wheezing amiodarone mg po bid duration week then mg bid x month then mg daily x month aspirin ec mg po daily docusate sodium mg po bid prn constipation first line furosemide mg po bid duration days then mg daily x days then fluid balance to be reassessed guaifenesin ml po q6h prn cough metoprolol tartrate mg po q8h hold for sbp hr potassium chloride meq po bid duration days then meq daily x days stop once lasix stops hold for k ranitidine mg po daily duration month senna mg po daily prn constipation first line hold for loose stools tiotropium bromide cap ih daily md to order daily dose po daily16 warfarin mg po once duration dose goal inr ascorbic acid mg po bid cyanocobalamin mcg po daily diclofenac sodium topical qid prn to affected area ipratropium bromide mdi puff ih tid multivitamins tab po daily simvastatin mg po qpm symbicort budesonide formoterol mcg actuation inhalation bid vitamin d unit po daily discharge disposition extended care facility diagnosis mitral regurgitation mitral valve prolapse s p mitral valve repair post operative atrial fibrillation anemia acute blood loss thrombocytopenia most likely secondary to blood loss leukocytosis secondary to stress response chronic heart failure with preserved ef secondary to valvular disease secondary diagnosis chronic bronchitis chronic obstructive pulmonary disease degenerative joint disease hyperlipidemia right foot hammer toe bilateral knee replacement bilateral thumb surgery appendectomy partial hysterectomy bladder sling surgery discharge condition alert and oriented x3 non focal ambulating with assistance person assist oob sternal pain managed with acetaminophen sternal incision healing well no erythema or drainage lower extremity edema discharge instructions please shower daily wash incisions gently with mild soap no baths or swimming look at your incisions daily please no lotion cream powder or ointment to incisions each morning you should weigh yourself and then in the evening take your temperature these should be written down on the chart no driving for approximately one month and while taking narcotics clearance to drive will be discussed at follow up appointment with surgeon no lifting more than pounds for weeks encourage full shoulder range of motion unless otherwise specified please call cardiac surgery office with any questions or concerns answering service will contact on call person during off hours females please wear bra to reduce pulling on incision avoid rubbing on lower edge followup instructions

name unit no admission date discharge date date of birth sex m service orthopaedics allergies no known allergies adverse drug reactions attending chief complaint left distal humerus fracture major surgical or invasive procedure open reduction internal fixation of left distal humerus fractures by dr on history of present illness male with no significant past medical history presenting after a bicycle accident patient was riding his bike when he braked too hard patient fell onto his left side patient was wearing a helmet no loss of consciousness patient was able to ambulate afterwards patient presents with significant left elbow pain and swelling patient has no significant past medical or surgical history he is not on any blood thinners past medical history none social history family history non contributory physical exam avss nad a ox3 rue posterior slab in place clean and dry fires epl fpl dio silt radial median ulnar n distributions radial pulse wwp distally pertinent results 08am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 17am blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 08am blood plt 08am blood ptt 08am blood glucose urean creat na k cl hco angap 08am blood calcium phos mg brief hospital course the patient presented to the emergency department and was evaluated by the orthopedic surgery team the patient was found to have a left distal humerus fracture and was admitted to the orthopedic surgery service the patient was taken to the operating room on for l humerus open reduction and internal fixation which the patient tolerated well for full details of the procedure please see the separately dictated operative report the patient was taken from the or to the pacu in stable condition and after satisfactory recovery from anesthesia was transferred to the floor the patient was initially given iv fluids and iv pain medications and progressed to a regular diet and oral medications by pod the patient was given antibiotics and anticoagulation per routine the patient s home medications were continued throughout this hospitalization the patient worked with who determined that discharge to home was appropriate the hospital course was otherwise unremarkable at the time of discharge the patient s pain was well controlled with oral medications dressings were clean dry intact and the patient was voiding moving bowels spontaneously the patient is non weight bearing in the left upper extremity range of motion as tolerated at shoulder wrist digits and will be discharged on aspirin for dvt prophylaxis the patient will follow up with dr routine a thorough discussion was had with the patient regarding the diagnosis and expected post discharge course including reasons to call the office or return to the hospital and all questions were answered the patient was also given written instructions concerning precautionary instructions and the appropriate follow up care the patient expressed readiness for discharge discharge medications acetaminophen mg po q4h aspirin mg po daily bisacodyl mg po pr daily prn constipation docusate sodium mg po bid oxycodone immediate release mg po q4h prn pain senna mg po bid discharge disposition home discharge diagnosis distal humerus fracture discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions instructions after orthopaedic surgery you were in the hospital for orthopedic surgery it is normal to feel tired or washed out after surgery and this feeling should improve over the first few days to week resume your regular activities as tolerated but please follow your weight bearing precautions strictly at all times activity and weight bearing nwb lue in posterior slab romat at shoulder wrist digits etc medications take tylenol every hours around the clock this is an over the counter medication add oxycodone as needed for increased pain aim to wean off this medication in week or sooner this is an example on how to wean down take tablet every hours as needed x day then tablet every hours as needed x day then tablet every hours as needed x day then tablet every hours as needed x days then tablet every hours as needed x day then tablet every before bedtime as needed x day then continue with tylenol for pain do not stop the tylenol until you are off of the narcotic medication per state regulations we are limited in the amount of narcotics we can prescribe if you require more you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone narcotic pain relievers can cause constipation so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list these meds senna colace miralax are over the counter and may be obtained at any pharmacy do not drink alcohol drive a motor vehicle or operate machinery while taking narcotic pain relievers please take all medications as prescribed by your physicians at discharge continue all home medications unless specifically instructed to stop by your surgeon anticoagulation please take aspirin 325mg for vte ppx x weeks wound care you may shower no baths or swimming for at least weeks any stitches or staples that need to be removed will be taken out at your week follow up appointment incision may be left open to air unless actively draining if draining you may apply a gauze dressing secured with paper tape if you have a splint in place splint must be left on until follow up appointment unless otherwise instructed do not get splint wet danger signs please call your pcp or surgeon s office and or return to the emergency department if you experience any of the following increasing pain that is not controlled with pain medications increasing redness swelling drainage or other concerning changes in your incision persistent or increasing numbness tingling or loss of sensation fever shaking chills chest pain shortness of breath nausea or vomiting with an inability to keep food liquid medications down any other medical concerns this patient is expected to require days of rehab follow up please follow up with your orthopaedic surgeon dr you will have follow up with np in the orthopaedic trauma clinic days post operation for evaluation call to schedule appointment upon discharge please follow up with your primary care doctor regarding this admission within weeks and for any new medications refills physical therapy activity activity activity as tolerated left upper extremity non weight bearing encourage turn cough and deep breathe q2h when awake treatments frequency any staples or superficial sutures you have are to remain in place for at least weeks postoperatively incision may be left open to air unless actively draining after pod3 if draining you may apply a gauze dressing secured with paper tape you may shower and allow water to run over the wound but please refrain from bathing for at least weeks postoperatively please remain in the splint until follow up appointment please keep your splint dry if you have concerns regarding your splint please call the clinic at the number provided followup instructions

name unit no admission date discharge date date of birth sex m service cardiothoracic allergies no known allergies adverse drug reactions attending chief complaint chest pain major surgical or invasive procedure urgent coronary artery bypass graft x3 left internal mammary artery to left anterior descending artery right internal mammary artery to distal right coronary artery and saphenous vein graft to obtuse marginal artery endoscopic harvesting of the long saphenous vein cardiac catheterization history of present illness year old male with a cardiac risk factor history of htn not compliant with meds dyslipidemia obesity and fh of premature cad presenting with intermittent exertional chest pain of days duration days pta he was in a fire and pulling out a hose when he suddenly felt a squeezing sensation in his chest which radiated to his neck and jaw he also had associated sob upon leaving work and on his way back to the fire house he had chest pain again and was seen at the ed and had a normal ekg and negative troponins x2 a stress test was suggested to further characterize but pt decided to leave the hospital he went to see his pcp yesterday who suggested he come back to the ed for coronary angiography throughout the weekend pt has noted some sob lightheadedness and intermittent chest pain sometimes occurring with rest the pain is less severe than it was on however it is a poking pain made worse with exertion and better with rest at baseline he does significant exercise for his work neither changes in position nor palpation make it better or worse he denies pleuritic chest pain he has previously experienced gerd and reports that this pain is different than his reflux sx he denies any orthopnea or nocturnal dyspnea his ros is pan negative except as mentioned above though he does endorse some fatigue over the past month that is not associated with weight loss fevers or night sweats in pt had a stress test at which noted horizontal downsloping st depressions in ii iii avf and v6 on the perfusion images there was a small area of decreased perfusion in the region was going to get a cath but due to scheduling difficulties did not was seen one time by a cardiologist who started him on atorvastatin and aspirin which he discontinued in the ed initial vitals were pain t97 hr84 bp rr ra ekg nsr w nonspecific t wave inversion in iii 1mm ste in i c w prior on labs studies notable for trop negative ua bacteria but neg wbc hgb cr patient was given asa 325mg atorvastatin mg acetaminophen for pain vitals on transfer pain t97 hr93 bp139 rr27 ra on the floor continues to have chest pain out of past medical history gerd hyperlipidemia hypertension obesity social history family history mother deceased cad dm cjd father alive w cad dm brother high cholesterol mgm mi mgf mi pgf mi sister mi physical exam on admission physical exam general wdwn male in nad heent ncat sclera anicteric perrl eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthelasma neck supple with no visible jvd cardiac rrr normal s1 s2 no murmurs rubs gallops no thrills lifts lungs no chest wall deformities scoliosis or kyphosis resp were unlabored no accessory muscle use no crackles wheezes or rhonchi abdomen soft ntnd w o rebound garuding extremities no c c e moving all extremities no femoral bruits neuro aox3 cnii xii intact skin no stasis dermatitis ulcers scars or xanthomas pulses distal pulses palpable and symmetric labs see below micro see below ekg nonspecific twi in iii and 1mm ste in i o w nsr normal axis and intervals w late r wave transition discharge physcial exam vital signs temp hr sbp ra dischareg wgt kg preop neuro non focal a o x resp diminished bases cv s1 s2 no jvd gi abd soft bs bm gu voiding clear yellow urine ext trace lower ext edema sternal incision and right evh healing no erythema or drainage pertinent results tte prebypass normal lv systolic function with lvef and no segmental wall motion abnormalities normal valves right ventricular chamber size and free wall motion are normal the aortic valve leaflets 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 pericardial effusion no clot seen in the normal coronary sinus intact interatrial septum postbypass lvef no disection seen following removal of the aortic cannula no new wall motion abnormalities following chest closure otherwise unchanged pa lat stable postoperative mediastinal widening small bilateral effusions are unchanged bibasilar atelectasis is improved 59am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 20pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 06am blood ptt 59am blood urean creat na k cl 20pm blood glucose urean creat na k cl hco3 angap 27am blood ptt 20pm blood vitb12 10am blood hba1c eag 11am blood triglyc hdl chol hd ldlcalc brief hospital course presented with chest pain and underwent cardiac catheterization that revealed significant coronary artery disease cardiac surgery was consulted and he underwent preoperative workup on was taken to the operating room for coronary artery bypass graft surgery please see operative report for further surgical details overall the patient tolerated the procedure well and post operatively was transferred to the cvicu in stable condition for recovery and invasive monitoring he required vasoactive medications for blood pressure management that were weaned off post operative day one early in the morning on post operative day one he was weaned from sedation awoke neurologically intact and was extubated without complications he was started on betablocker and diuretic continued to progress and later that day was transferred to the floor chest tubes and pacing wires were discontinued without complication the patient was evaluated by the physical therapy service for assistance with strength and mobility he was postoperatively anemic likely due to volume resuscitation and he deferred transfusion however on post operative day five he was feeling symptomatic on ambulation with increased fatigue and lightheadedness he was transfused one unit of packed red blood cells with resolution he continued to improve and was ready for discharge home with services on post operative day six medications on admission the preadmission medication list is accurate and complete albuterol sulfate mcg actuation inhalation q4h prn sob omeprazole mg po daily atorvastatin mg po qpm of note pt reports not taking any of these medications despite having prescriptions discharge medications atorvastatin mg po qpm rx atorvastatin mg tablet s by mouth once a day disp tablet refills aspirin ec mg po daily docusate sodium mg po bid tramadol ultram mg po q4h prn pain rx tramadol ultram mg tablet s by mouth every four hours disp tablet refills ibuprofen mg po q8h prn pain take with food furosemide mg po daily duration days rx furosemide mg tablet s by mouth once a day disp tablet refills guaifenesin er mg po q12h rx guaifenesin mg tablet s by mouth twice a day disp tablet refills albuterol sulfate mcg actuation inhalation q4h prn sob omeprazole mg po daily polyethylene glycol g po daily hold for loose stools metoprolol tartrate mg po bid rx metoprolol tartrate lopressor mg tablet s by mouth twice a day disp tablet refills hydromorphone dilaudid mg po q3h prn pain rx hydromorphone dilaudid mg tablet s by mouth q3h disp tablet refills discharge disposition home with service facility discharge diagnosis coronary artery disease s p revascularization anemia acute blood loss secondary diagnosis hypertension hyperlipidemia discharge condition alert and oriented x3 nonfocal ambulating gait steady sternal pain managed with dilaudid tylenol ultram sternal incision healing well no erythema or drainage right leg incision healing well no erythema or drainage edema trace edema discharge instructions please shower daily including washing incisions gently with mild soap no baths or swimming and look at your incisions please no lotions cream powder or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature these should be written down on the chart no driving for approximately one month and while taking narcotics will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than pounds for weeks please call with any questions or concerns please call cardiac surgery office with any questions or concerns answering service will contact on call person during off hours followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies clindamycin naproxen sulfa sulfonamide antibiotics e mycin attending chief complaint abdominal pain major surgical or invasive procedure egd history of present illness ms is a very pleasant yo female with pmhx niddm and child s a cirrhosis previously complicated by variceal bleed s p banding who presents today with week of abdominal pain ms first presented to week ago with abdominal pain she describes a dull constant recurrent upper abdominal pain that is present throughout the day changing position somewhat worsens the pain in her belly and tylenol helps take the edge off she notes no relation to po intake and has been able to tolerate po though notes some nausea she also notes burning substernal chest pain yesterday that lasted for minutes and then subsided she presented to in with the above complaints was there for days and told she had inflammation of the pancreas she eventually left against medical advice because she felt that staff there was rude to her her pain persisted on her departure and she presented to ed for further diagnosis and management past medical history niddm prior obesity cirrhosis variceal bleed at presented with coffee ground emesis and melena and was found to have grade ii varices banded x3 also with gastric erosion noted with contact bleeding that required clipping per report no description of high risk stigmatata or active bleeding no biopsies taken chronic back pain after a fall years ago is on disability and ambulates with a walker cad she was seen at several months ago with chest pain and underwent exercise stress test she was told she has angina and was given prn nitro asthma anxiety gerd prior obesity osteporosis gout past surgical history appendectomy hysterectomy c s x3 social history family history mother heart attackx3 father stroke brother who died secondary to alcohol cirrhosis brother with cancer daughter thinks she may have fatty liver disease physical exam admission physical exam vs temp bp hr rr sao2 ra general well appearing woman in nad aaox3 pleasant and conversational able to recite days of week forwards and backwards without issue heent at nc eomi perrl anicteric sclera pink conjunctiva mmm neck supple no lad no jvd heart rrr s1 s2 no murmurs gallops or rubs lungs ctab no wheezes rales rhonchi breathing comfortably without use of accessory muscles tender depression noted over right 10th rib abdomen redundant skin folds soft non distended no discernible bulging flanks or fluid wave noted tenderness with voluntary guarding in epigastrium no hepatomegaly appreciated extremities no cyanosis clubbing or edema pulses dp pulses bilaterally neuro moving all extremities with purpose no asterixis skin warm and well perfused no excoriations or lesions no rashes discharge physical exam vs ra general lying in bed appears comfortable and relatively well heent poor dentition thin hair no scleral icterus cardiac normal s1 and s2 pulmonary clear to auscultation without rales rhonchi wheezing or diminished breath sounds abdomen soft mildly tender to palpation of abdomen in the epigastric area neuro alert and oriented x3 no gross focal deficits no asterixis skin no rashes pertinent results admission labs 36pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 36pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 36pm blood plt 36pm blood glucose urean creat na k cl hco3 angap interval labs 40pm blood alt ast alkphos totbili 40pm blood lipase 40pm blood albumin 35am blood albumin calcium phos mg 28am blood ck mb ctropnt imaging ct a p impression the liver has a nodular border the spleen is enlarged gastric varices are evident there is a small amount of ascites findings are most compatible with cirrhosis and portal hypertension sub cm right renal lesions which are too small for accurate characterization but statistically likely represent tiny cysts diverticulosis impression cirrhotic liver morphology with sequela of portal hypertension including splenomegaly and intra abdominal varices no suspicious focal hepatic lesion no evidence of pancreatitis discharge labs 09am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 09am blood plt 28am blood ptt 09am blood glucose urean creat na k cl hco3 angap 09am blood alt ast alkphos totbili 09am blood albumin calcium phos mg brief hospital course ms is a year old woman with likely nash childs b cirrhosis c b ascites and esophageal variceal bleeding who presents with acute abdominal pain with negative workup thus far except portal gastropathy acute abdominal pain patient presents with an episode of acute abdominal pain these episodes have been occurring frequently with multiple hospitalizations testing prior to this admission thus far had been unrevealing multiple cts abdomen pelvis ctas of chest and a stress test to rule out cardiac etiology low suspicion for gyn pathology given hysterectomy years ago egd was done and revealed evidence of portal gastropathy and varices but no ulcers mrcp showed no evidence biliary pathology unlikely pancreatitis looks extremely well and ct mrcp not supportive unlikely that pain could be due to metformin side effect patient treated supportively with maalox and ppi amitryptiline was started at night for pain control in case there was a component of nerve involvement she will need follow up with gi on discharge for monitoring further evaluation and pain management nash cirrhosis patient with child s b cirrhosis no biopsy proven diagnosis but likely nash given her history of obesity and metabolic syndrome with htn and t2dm she presented with volume overload with edema mild ascites and varices she had ascites on imaging not previously seen on prior workup however there was no pocket to tap she had not been taking her home spironolactone and lasix for a month prior to admission started on home spironolactone and double lasix dose to bid dosing edema improved and she was discharged with home lasix dosing egd with evidence of varices as above cad patient with recent history of angina stress test was performed negative therefore this is not a fair diagnosis troponin negative at osh and on this admission on gerd continued omeprazole mg po daily maalox given for symptomatic relief dm ii home metformin was held on admission patient was given iss transitional issues patient was not taking lasix or spironolactone at home please follow up volume status blood pressure and chemistry panel at follow up appointment and adjust dosing as appropriate continue to work up abdominal pain as outpatient pcp and gi follow up consider referral to pain clinic for chronic abdominal pain of unknown etiology needs hbv vaccine series discharge weight lb discharge cr new meds amitriptyline mg po ng qhs acetaminophen mg po ng q8h lidocaine patch ptch td qam maalox diphenhydramine lidocaine ml po tid restarted meds wasn t taking for month furosemide mg po ng daily spironolactone mg po ng bid contact phone number code full confirmed medications on admission the preadmission medication list is accurate and complete metformin glucophage mg po bid ferrous sulfate mg po daily furosemide mg po daily spironolactone mg po bid omeprazole mg po daily discharge medications acetaminophen mg po q8h rx acetaminophen mg tablet s by mouth every hours disp tablet refills amitriptyline mg po qhs rx amitriptyline mg tablet s by mouth every night before bed disp tablet refills maalox diphenhydramine lidocaine ml po tid abdominal pain rx calcium carbonate simethicone antacid anti gas ca mg mg ml by mouth three times a day disp bottle refills ferrous sulfate mg po daily furosemide mg po daily rx furosemide mg tablet s by mouth daily disp tablet refills metformin glucophage mg po bid omeprazole mg po daily spironolactone mg po bid rx spironolactone mg tablet s by mouth two times a day disp tablet refills discharge disposition home discharge diagnosis primary diagnosis idiopathic acute abdominal pain secondary diagnoses nash cirrhosis gerd diabetes mellitus type ii discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms it was a pleasure taking part in your care here at why was i admitted to the hospital you were admitted for belly pain what happened to me in the hospital a ct scan of your belly was done which did not show any signs of intestinal obstruction or infection it did show cirrhosis of your liver an endoscopy was done to look at your esophagus stomach and intestines no ulcers were seen no bleeding was seen there were signs of dilated veins in your esophagus which are called varices an mri of your liver was done which showed a normal pancreas and liver cirrhosis what should i do when i leave the hospital please take all of your medicines as prescribed please follow up with a gi doctor as listed in the appointments below please follow up with your new pcp as listed in the appointments below you will need labs at your next appointment please do not smoke or drink alcohol please try to avoid fatty fried foods you should avoid eating right before bedtime when should i come back to the hospital you should come back to the hospital if you have worsening abdominal pain fevers sincerely your treatment team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies clindamycin naproxen sulfa sulfonamide antibiotics e mycin ibuprofen attending chief complaint epigastric abdominal pain concern for upper gi bleed major surgical or invasive procedure n a history of present illness is a year old woman with a h o htn niddm cirrhosis c b ascites and esophageal variceal bleeding in s p banding x who presents with chest pain and abdominal pain one day pta she reports waking up with severe constant non radiating epigastric pain associated with nausea morning when she woke up she noted a small volume of bright red blood in her mouth and throat estimated around a few cc s she is afraid of a recurrent variceal bleed since that episode started similarly in the ed she experienced midline l sided chest pressure radiating to her neck and lue it was associated with dyspnea on exertion it is not worse with any position or with inspiration she reports that it feels similar to a previous episode when she was admitted to the hospital with a possible heart attack and was given nitroglycerin she has no known ascvd she denies any fevers chills cough abdominal distention vomiting diarrhea melena hematochezia rash back pain no recent travel no sick contacts prior smoker no alcohol no illicit substances in the ed initial vitals ra exam notable for gen uncomfortable appearing cv rrr nl s1 s2 no m r g pain not reproducible with palpation resp ctab abd soft non distended bulging flanks shifting dullness or fluid wave markedly ttp in midline epigastrium digital rectal exam guaiac negative ext pulses no c c e labs notable for hgb then baseline plts and then baseline inr at baseline chem panel unremarkable ast alt mildly uptrending lipase trop negative x2 ua with trace ketone trace leuks few bacteria and epi urine cx sent imaging notable for ruqus w doppler patent vasculature no ascites cirrhotic liver containing and a cm echogenic lesion in segment not definitively seen on recent mr from recommend short term mr in months patent hepatic vasculature hepatology was consulted and recommended while unlikely variceal bleed pt is high risk given history start octreotide gtt and ppi iv bid two large bore pivs and type and screen transfuse prn start ceftriaxone for gib in cirrhotic would consider abdominal chest imaging to rule out pancreatitis cholecystitis etc to explain pt recent ab chest pain and n v a dmit to et service under dr given morphine 4mg iv x octreotide gtt ceftriaxone 1gm at at iv ppi with esomeprazole furosemide 20mg po potassium chloride 10mg po vitals prior to transfer ra on the floor the patient reports non radiating pain in the epigastrium that began suddenly four days ago she had one episode of bright red blood in her mouth upon waking no coffee ground emesis or true hematemesis mouth has been very dry she has had no nasopharyngeal bleeding she has had intermittent nausea without vomiting she had two episode of sharp pain in her chest once along left axilla secondly along r sternum both without pressure she has frontal headache she has no fever or chills she has felt fatigued she has been experiencing hair loss past medical history niddm prior obesity cirrhosis variceal bleed at presented with coffee ground emesis and melena and was found to have grade ii varices banded x3 also with gastric erosion noted with contact bleeding that required clipping per report no description of high risk stigmatata or active bleeding no biopsies taken chronic back pain after a fall years ago is on disability and ambulates with a walker cad she was seen at several months ago with chest pain and underwent exercise stress test she was told she has angina and was given prn nitro asthma anxiety gerd prior obesity osteporosis gout past surgical history appendectomy hysterectomy c s x3 social history family history mother heart attackx3 father stroke brother who died secondary to alcohol cirrhosis brother with cancer daughter thinks she may have fatty liver disease physical exam admission physical exam vitals po ra general aox3 nad heent normocephalic atraumatic pupils are equal round and reactive to light and accommodation constricting from to mm b l eomi in all cardinal directions of gaze with horizontal end gaze nystagmus b l vision is grossly intact hearing grossly intact nares patent with no nasal discharge oral cavity and pharynx are without inflammation swelling exudate or lesions teeth and gingiva in poor general condition cardiac normal s1 and s2 no s3 s4 there is a iii vi midsystolic murmur in rusb rhythm is regular there is no peripheral edema cyanosis or pallor extremities are warm and well perfused pulmonary clear to auscultation without rales rhonchi wheezing or diminished breath sounds abdomen normoactive bowel sounds soft minimally distended tender to palpation in the epigastrium no guarding or rebound no masses neuro alert and oriented x3 no gross focal deficits no asterixis present cn2 intact strength througout normal sensation no ataxia dysmetria disdiadochokinesia psych appropriate mood and affect skin skin type iii skin normal color texture and turgor with no lesions or eruptions discharge physical exam general aox3 nad heent normocephalic atraumatic perrla eomi op clear cardiac rrr normal s1 and s2 iii visem rusb pulmonary clear to auscultation without rales rhonchi wheezing or diminished breath sounds abdomen normoactive bowel sounds soft minimally distended nontender no guarding or rebound no masses neuro alert and oriented x3 no gross focal deficits no asterixis present cn2 intact strength throughout psych appropriate mood and affect skin wwp extremities no edema pertinent results admission labs 08pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 08pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 08pm blood plt 08pm blood glucose urean creat na k cl hco3 angap 08pm blood alt ast alkphos totbili 08pm blood lipase 08pm blood ctropnt 35pm blood ctropnt 20pm blood albumin calcium phos mg 41pm blood lactate 00pm urine color yellow appear hazy sp 00pm urine blood neg nitrite neg protein glucose neg ketone tr bilirub neg urobiln ph leuks tr 00pm urine rbc wbc bacteri few yeast none epi 00pm urine casthy discharge labs 11am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 35pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 11am blood ptt 11am blood glucose urean creat na k cl hco3 angap 11am blood alt ast alkphos totbili 11am blood albumin calcium phos mg micro pm urine final report urine culture final mixed bacterial flora colony types consistent with skin and or genital contamination studies chest pa lat study date of findings the lungs are clear there is no focal consolidation effusion or pneumothorax the cardiomediastinal silhouette is within normal limits no acute osseous abnormalities impression no acute cardiopulmonary process liver or gallbladder us single organ study date of findings liver the hepatic parenchyma is coarsened and nodular a cm echogenic lesion in segment of the liver is noted without a definite correlate on recent mr from there is no ascites bile ducts there is no intrahepatic biliary ductal dilation the common hepatic duct measures mm gallbladder the gallbladder contains sludge pancreas the imaged portion of the pancreas appears within normal limits with portions of the pancreatic tail obscured by overlying bowel gas spleen the spleen demonstrates normal echotexture and measures cm doppler evaluation the main portal vein is patent with flow in the appropriate direction main portal vein velocity is cm sec right and left portal veins are patent with antegrade flow the main hepatic artery is patent with appropriate waveform right middle and left hepatic veins are patent with appropriate waveforms splenic vein and superior mesenteric vein are patent with antegrade flow impression cirrhotic liver containing and a cm echogenic lesion in segment not definitively seen on recent mr from recommend short term mr in months patent hepatic vasculature brief hospital course with likely a cirrhosis c b ascites and esophageal variceal bleeding s p banding who presents with acute epigastric abdominal pain and an episode of bright red blood in mouth etiology of blood in mouth thought to be related to oropharyngeal bleeding from poor dentition vs variceal bleed patient was treated with ceftriaxone and octreotide gtt cbc remained stable despite extensive discussion patient requested to leave against medical advice prior to endoscopy for evaluation of varices patient able to state risks of this decision including recurrent bleeding and death she was given prescription for 5d course of ciprofloxacin to prevent infection in the setting of possible gi bleed etiology of abdominal pain remained unclear patient had previously described a similar pain during her last admission work up at that time including mrcp was largely unrevealing on this admission labs including lfts and lipase were stable repeat ruqus was without acute without changes cardiac w u negative pain spontaneously resolved transitional issues 1cm liver lesion noted on ruqus on admission consider mri within months for further characterization consider f u with dentistry given dentition continue ciprofloxacin 500mg bid x days through for infectious prophylaxis in the setting of possible gi bleed consider repeat cbc at next hepatology appointment to ensure stability f u with hepatology regarding h o varices and appropriate timing of next egd medications on admission the preadmission medication list is accurate and complete furosemide mg po daily omeprazole mg po daily spironolactone mg po bid acetaminophen mg po q8h metformin glucophage mg po bid multivitamins tab po daily hydrocodone acetaminophen 5mg 325mg tab po q8h prn pain severe discharge medications ciprofloxacin hcl mg po q12h duration hours through rx ciprofloxacin hcl mg tablet s by mouth every hours disp tablet refills acetaminophen mg po q8h furosemide mg po daily hydrocodone acetaminophen 5mg 325mg tab po q8h prn pain severe metformin glucophage mg po bid multivitamins tab po daily omeprazole mg po daily spironolactone mg po bid discharge disposition home discharge diagnosis primary diagnosis possible hematemesis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms why was i admitted to the hospital you were admitted to the hospital with abdominal pain and with blood in your mouth what happened while i was in the hospital we monitored your blood counts we treated you with medication to help prevent bleeding and medicine to help prevent infection you chose to leave against medical advice before we were able to evaluate you for bleeding from your stomach you expressed that you understand the risks of this decision what should i do when i go home please take antibiotics to prevent infection through take your medications as prescribed keep your follow up appointments with your team of doctors if you experience any abdominal pain or bleeding including dark colored stool or bright red blood please go to the nearest emergency room immediately thank you for letting us be a part of your care your team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies clindamycin naproxen sulfa sulfonamide antibiotics e mycin ibuprofen attending chief complaint abd pain subacute weight loss major surgical or invasive procedure none history of present illness year old woman with a h o htn niddm cirrhosis class a complicated ascites and esophageal variceal bleeding in s p banding x who presents with abdominal pain and lightheadedness in addition to a 70lb weight loss over months patient states that since she had her esophageal banding she has been having trouble swallowing and has had decreased appetite as a result she reports a pounds over the last months she says for the last month in addition to difficulty with eating she has had abdominal pain this worsened over the last week or so which caused her to present to she was there for the last days or so and says that they did not do anything for her there she says they treated her stomach pain with pain medicines but otherwise no changes were made to her medication regimen she states that a month ago when the abdominal pain began she had some vomiting but since then has not had any vomiting she does have occasional nausea she denies any diarrhea chest pain shortness of breath fevers chills dysuria she does endorse some lightheadedness over the past week she states that while she was at she did have a fall while she was in the bathroom she endorses compliance with her medications she left ama because she felt as though they were not giving her any answers of note she had a recent admission to in late with a chief complaint of abdominal pain as well she left ama on that admission before endoscopy etiology of her abdominal pain remained unclear she also had another previous admission for abdominal pain during which workup was negative right upper quadrant ultrasound lfts and lipase were unremarkable cardiac workup was negative mrcp was unremarkable in the ed initial vs were ra exam notable for chronically ill mild llq rlq abdominal tenderness no asterixis ekg sr normal axis normal pr ivcd qtc nonspecific st t changes without e o territorial ischemia labs showed na k cl bicarb bun cr glu ca mg p lactate inr a1c imaging showed ct head w o contrast no acute intracranial hemorrhage ct abd pelvis distended terminal ileum with fecalized material suggestive of slow transit no bowel obstruction cirrhotic liver without evidence of hepatic lesion mild gallbladder wall edema is likely related to underlying liver disease stigmata portal hypertension including patent periumbilical vein splenomegaly and varices patent portal vein cxr findings heart size is top normal the mediastinal and hilar contours are within normal limits the pulmonary vasculature is normal the lungs appear clear no focal consolidation pleural effusion or pneumothorax is seen clips are noted in the left upper quadrant of the abdomen there are no acute osseous abnormalities impression no acute cardiopulmonary abnormality consults hepatology patient received 50g albumin iv morphine sulfate 2mg iv x transfer vs were ra on arrival to the floor patient reports ongoing abdominal pain she is tearful at times otherwise she is in no acute distress review of systems point ros reviewed and negative except as per hpi past medical history niddm prior obesity cirrhosis class a variceal bleed at osh presented with coffee ground emesis and melena and was found to have grade ii varices banded x3 also with gastric erosion noted with contact bleeding that required clipping per report no description of high risk stigmatata or active bleeding no biopsies taken chronic back pain after a fall years ago is on disability and ambulates with a walker cad she was seen at several months ago with chest pain and underwent exercise stress test she was told she has angina and was given prn nitro asthma anxiety gerd prior obesity osteporosis gout past surgical history appendectomy hysterectomy c s x3 social history family history mother heart attackx3 father stroke brother who died secondary to alcohol cirrhosis brother with cancer daughter thinks she may have fatty liver disease physical exam admission physical exam vs temp po bp l lying hr rr o2 sat o2 delivery ra general chronically ill appearing lady tearful otherwise nad heent at nc eomi perrl anicteric sclera pink conjunctiva very poor dentition no thrush neck supple no lad no jvd heart rrr s1 s2 systolic flow murmur at sternal border lungs ctab no wheezes rales rhonchi breathing comfortably without use of accessory muscles abdomen nondistended no visible ascites tender to palpation in left upper and lower quadrants with voluntary guarding extremities no cyanosis clubbing or edema pulses dp pulses bilaterally neuro no asterixis a ox3 moving all extremities with purpose skin warm and well perfused no excoriations or lesions no rashes discharge physical exam vs po l lying ra general chronically ill appearing lady tearful otherwise nad heent at nc eomi perrl anicteric sclera pink conjunctiva very poor dentition no thrush neck supple no lad no jvd heart rrr s1 s2 systolic flow murmur at sternal border lungs ctab no wheezes rales rhonchi breathing comfortably without use of accessory muscles abdomen nondistended no visible ascites tender to palpation in left upper and lower quadrants with no guarding or rebound extremities no cyanosis clubbing or edema pulses dp pulses bilaterally neuro no asterixis a ox3 moving all extremities with purpose skin warm and well perfused no excoriations or lesions no rashes pertinent results laboratory studies 07pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 07pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 07pm blood ptt 07pm blood glucose urean creat na k cl hco3 angap 07pm blood alt ast alkphos totbili 07pm blood lipase 07pm blood albumin calcium phos mg 14pm blood hba1c eag 16pm blood lactate 15am blood lactate imaging reports ct scan abd pelvis distended terminal ileum with fecalized material suggestive of slow transit no bowel obstruction cirrhotic liver without evidence of a focal hepatic lesion on this single phase exam mild gallbladder wall edema is likely related to underlying liver disease stigmata portal hypertension including patent periumbilical vein splenomegaly and varices patent portal vein ct head no acute intracranial hemorrhage cxr no acute cardiopulmonary abnormality brief hospital course brief summary year old woman with a h o htn niddm cirrhosis class a complicated ascites and esophageal variceal bleeding in s p banding x who presents with abdominal pain in addition to unintentional weight loss over months workup during admission unremarkable and pain improved during admission active issues abdominal pain patient presented with left sided abdominal pain and weight loss for which she has required multiple recent admissions despite extensive workup over the past few admissions the etiology of the abdominal pain remains unclear workup during admission showed afebrile and hemodynamically stable and unremarkable laboratory studies ct scan of the abdomen showed distended terminal ileum with fecalized material suggestive of slow transit but no bowel obstruction or other acute process it is possible that constipation or gastroparesis may be contributing patient was treated with pain medications the etiology of the pain remained unclear and actually improved during the hospitalization and the patient requested to go home moderate malnutrition evaluated by nutrition during the hospitalization and found to have moderate malnutrition recommended frappe w pkt beneprotein tid and multivitamin chronic issues nash cirrhosis remained compensated during admission continued home spironolactone and furosemide niddm held home metformin given humalog sliding scale during admission transitional issues needs outpatient workup of microscopic hematuria needs follow up with dr consider outpatient endoscopy consider further workup as an outpatient of dysphagia consider speech and swallow evaluation patient should have further workup of abdominal pain as an outpatient code full presumed contact medications on admission the preadmission medication list is accurate and complete furosemide mg po daily spironolactone mg po bid acetaminophen mg po q8h hydrocodone acetaminophen 5mg 325mg tab po q8h prn pain severe metformin glucophage mg po bid multivitamins tab po daily omeprazole mg po daily albuterol inhaler puff ih q4h prn wheezing cyclobenzaprine mg po tid prn muscle spasm discharge medications polyethylene glycol g po daily senna mg po bid acetaminophen mg po q12h prn pain mild albuterol inhaler puff ih q4h prn wheezing cyclobenzaprine mg po tid prn muscle spasm furosemide mg po daily hydrocodone acetaminophen 5mg 325mg tab po q8h prn pain severe rx hydrocodone acetaminophen mg mg tablet s by mouth q8h prn disp tablet refills metformin glucophage mg po bid multivitamins tab po daily omeprazole mg po daily spironolactone mg po bid discharge disposition home discharge diagnosis abdominal pain cirrhosis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear ms it was a pleasure taking care of you at please see below for information on your time in the hospital why was i in the hospital you were admitted to the hospital for abdominal pain what happened in the hospital you were given pain medications for your abdominal pain laboratory studies and a ct scan of your abdomen did not show any thing concerning what should i do when i go home please continue to take your medications as prescribed please schedule an appointment with your primary care provider and your liver doctor maximum 2g tylenol per day we wish you the best your care team at followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies clindamycin naproxen sulfa sulfonamide antibiotics e mycin ibuprofen attending chief complaint dysphagia major surgical or invasive procedure egd history of present illness with history of asthma htn niddm cirrhosis class a c b ascites and esophageal banding x3 presents to the ed c o abdominal pain and a 100lb weight loss over the past months she reports that since her esophageal banding she has had difficulty eating she has an appetite and can swallow without pain but the food feels like it gets stuck and then she vomits which causes her stomach to hurt as a result she is scared to eat she has the same symptoms with solids and liquids and has been unable to keep down her medications she reports a mild slowly progressive headache nausea sob positional vertigo and diffuse abdominal pain she denies fever hematemesis chest pain cough diarrhea melena or brbpr of note she has been seen at several different hospitals including and where she leaves ama she was recently discharged from where a work up was unremarkable in the ed initial vs were hr bp rr 100ra exam notable for general tearful heent perrla no jaundice poor dentition cardiovascular rrr no appreciable murmur respiratory cta bilaterally no wheezing or rhonchi gi abdomen soft diffusely tender no rebound or guarding skin warm and dry musculoskeletal no peripheral edema labs showed wbc plt bicarb ua lg leuks wbc epi imaging showed gallbladder us cirrhotic liver morphology with multiple new areas hypodensity largest lesion measuring up to x x cm in the right lobe of the liver recommend nonemergent short term follow up mri for further assessment of these lesions portal venous system is patent recanalized periumbilical vein is consistent with sequela of portal hypertension no ascites patient received ivf iv morphine transfer vs were ra on arrival to the floor patient reports above symptoms reports abdominal pain improved she reports about a lb weight loss estimate from before first egd in for variceal bleeding she describes likely esophageal dysphagia with no problems initiating swallow has normal transit of food but then has stuck sensation in epigastric region she is tearful as she hasn t been able to eat has been able to take down soft foods oats but has not taken most of her medications has trouble with large pills she denies fevers chills constipation or diarrhea no night sweats she went to about a week ago for similar symptoms had a reported egd which was negative review of systems point ros reviewed and negative except as per hpi past medical history niddm prior obesity cirrhosis cph class a variceal bleed at osh presented with coffee ground emesis and melena and was found to have grade ii varices banded x3 also with gastric erosion noted with contact bleeding that required clipping per report no description of high risk stigmatata or active bleeding no biopsies taken chronic back pain after a fall years ago is on disability and ambulates with a walker cad she was seen at several months ago with chest pain and underwent exercise stress test she was told she has angina and was given prn nitro asthma anxiety gerd prior obesity osteporosis gout past surgical history appendectomy hysterectomy c s x3 social history family history mother heart attackx3 father stroke brother who died secondary to alcohol cirrhosis brother with cancer daughter thinks she may have fatty liver disease physical exam admission physical vs ra lbs general chronically ill appearing lady tearful on exam heent perrl anicteric sclera pink conjunctiva mmm neck supple no lad no jvd no cervical or axillary lymphadenopathy heart rrr s1 s2 systolic flow murmur at sternal border lungs ctab no wheezes rales rhonchi abdomen nondistended mild epigastric tenderness no rebound no guarding no palpable masses extremities no cyanosis clubbing or edema pulses dp pulses bilaterally neuro a ox3 moving all extremities with purpose skin warm and well perfused no excoriations or lesions no rashes discharge physical vs hr data last updated temp tm bp hr rr o2 sat o2 delivery ra wt lb kg general nad heent perrl anicteric sclera pink conjunctiva mmm neck supple no lad no jvd no cervical or axillary lymphadenopathy heart rrr s1 s2 systolic murmur at sternal border lungs ctab no wheezes rales rhonchi abdomen nondistended mild epigastric tenderness no rebound no guarding extremities no cyanosis clubbing or edema pulses dp pulses bilaterally neuro a ox3 moving all extremities with purpose skin warm and well perfused no excoriations or lesions no rashes pertinent results admission labs 15pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 15pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 15pm blood ptt 15pm blood glucose urean creat na k cl hco3 angap 15pm blood alt ast ld ldh alkphos totbili 15pm blood albumin calcium phos mg 55pm urine color yellow appear clear sp 55pm urine blood neg nitrite neg protein neg glucose neg ketone neg bilirub neg urobiln neg ph leuks lg 55pm urine rbc wbc bacteri few yeast none epi micro urine culture contaminated skin or gut types imaging ruqus cirrhotic liver morphology with several hypodense nodules largest measuring up to x x cm in the right lobe of the liver recommend mri for further assessment of these lesions portal venous system is patent recanalized periumbilical vein is consistent with sequela of portal hypertension no ascites triple phase ct sequela of liver cirrhosis and portal hypertension with splenomegaly trace ascites and upper abdominal varices egd esophagus lumen a benign intrinsic mm stricture was seen this was 3cm from the ge junction likely related to previous banding the dilation was started at a balloon which was introduced for dilation and the diameter was progressively increased to fr successfully no disruption of the stricture was noted until 15mm there was evidence of disruption after with a small amount of post procedural oozing no significant bleeding other no varices were seen in the esophagus stomach mucosa erythema and congestion in a mosaic pattern of the mucosa were noted in the throughout stomach these findings are compatible with portal hypertensive gastropathy protruding lesions many polyps of benign appearance and ranging in size from mm to mm were found in the body and fundus other an old clip was seen in t he stomach body duodenum flat lesions a single erythematous 3mm spot was noted in the duodenum it had a benign appearance no visible blood vessels or bleeding other numerous small 1mm lymphangectasias were seen in the proximal duodenum impression esophageal stricture dilation no varices were seen in the esophagus erythema and gongestion in a mosaic pattern in the throughout stomach compatible with portal hypertensive gastropathy polyps in the body and fundus spot in the duodenum numerous small 1mm lymphangectasias were seen in the proximal duodenum an old clip was seen in t he stomach body otherwise normal egd to third part of the duodenum discharge labs 54am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 54am blood glucose urean creat na k cl hco3 angap 54am blood alt ast alkphos totbili 54am blood calcium phos mg year old woman with a h o htn niddm nash cirrhosis class a complicated by ascites and esophageal variceal bleeding in s p banding x who presented with abdominal pain and dysphagia active issues esophageal stricture dysphagia vomiting similar presentation to recent admission at end of with diffuse abdominal pain and weight loss patient reported multiple other admissions confirmed by chart review with multiple cts abdomen pelvis ctas of chest and a stress test in the past to rule out cardiac etiology despite extensive workup no clear etiology of pain last ct scan of the abdomen showed distended terminal ileum with fecalized material suggestive of slow transit but no bowel obstruction or other acute process dysphagia ddx includes tumors malignancy vs stricture vs esophagitis vs a primary motility disorder recent records indicate egd with dilation of 4cm inner diameter stenosis in distal third of esophagus dilated with balloon to 15mm with moderate improvement in stenosis otherwise egd notable for portal hypertensive gastropathy based on this data the patient underwent egd on with a repeat dilation due to a mm stricture noted in distal esophagus also with portal hypertensive gastropathy the patient tolerated the procedure well and was able to eat solid food without side effects patient was continued on metoclopramide for presumed gastroparesis she was also placed on standing bowel regimen with senna and miralax she was continued on omeprazole mg daily that was doubled from her home dose she is also continued on home percocet as she had a narcotics contract with nash cirrhosis childs a history of ascites and esophageal variceal bleeding s p banding x3 patient presented with no evidence of decompensation during current admission she was continued on home spironolactone and furosemide a triple phase ct was performed which did not reveal any evidence of hcc moderate malnutrition nutrition was consulted for further recommendations and the patient was continued on frappes w pkt beneprotein tid and a multivitamin chronic issues niddm patient s home metformin was held and she was placed on insulin sliding scale while hospitalized back pain chronic lumbar and cervical pain patient had established a narcotics contract at associates hence she was continued on her established home pain regimen of percocet transitional issues consider outpatient egd in weeks if patient remains symptomatic as she has history of recurrent strictures requiring dilation ensure patient attends liver appointment as she is overdue for follow up code full presumed contact daughter medications on admission the preadmission medication list may be inaccurate and requires futher investigation acetaminophen mg po q12h prn pain mild albuterol inhaler puff ih q4h prn wheezing cyclobenzaprine mg po tid prn muscle spasm furosemide mg po daily multivitamins tab po daily omeprazole mg po daily spironolactone mg po bid polyethylene glycol g po daily senna mg po bid hydrocodone acetaminophen 5mg 325mg tab po q8h prn pain severe metformin glucophage mg po bid discharge medications metoclopramide mg po bid rx metoclopramide hcl mg by mouth twice a day disp tablet refills acetaminophen mg po q12h prn pain mild albuterol inhaler puff ih q4h prn wheezing furosemide mg po daily hydrocodone acetaminophen 5mg 325mg tab po q8h prn pain severe metformin glucophage mg po bid multivitamins tab po daily omeprazole mg po daily polyethylene glycol g po daily senna mg po bid spironolactone mg po bid held cyclobenzaprine mg po tid prn muscle spasm this medication was held do not restart cyclobenzaprine until you discuss with your primary care doctor discharge disposition home discharge diagnosis primary diagnoses esophageal stricture dysphasia vomiting secondary diagnoses nash cirrhosis moderate malnutrition diabetes mellitus type ii chronic back lumbar 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 in the hospital why was i admitted to the hospital you came to the hospital because you had difficulty swallowing what happened while i was admitted to the hospital ultrasound and a ct scan of your liver were performed which showed no abnormalities an egd was performed where a camera at the end of a tube was the use take a look inside your food pipe because you told us that you have had this procedure done at recently and felt that they may have performed a dilation the egd showed that the section of your food pipe connecting to your stomach was narrowed again and was widened further to help you swallow easier your lab numbers were closely monitored and you were continued on your home medications what should i do after i leave the hospital please continue taking all of your medications as prescribed details below keep all of your appointments as scheduled we wish you the very best your care team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies clindamycin naproxen sulfa sulfonamide antibiotics e mycin ibuprofen attending chief complaint abdominal pain major surgical or invasive procedure none history of present illness ms is a year old woman with a h o htn nidd cirrhosis class a complicated by ascites and esophageal variceal bleeding in s p banding x who presents with recurrent abdominal pain and dysphagia last discharged on for chief complaint of abdominal pain and dysphagia and had an egd on with esophageal dilation due to a mm stricture noted in distal esophagus days after leaving the hospital she felt crappy weak lethargy and had belly pain that would radiate into the chest this is the same pain that she has had in the past that would get better after dilation procedures this time the belly pain came back two days after leaving the hospital the pain got progressively worse the pain is exacerbated with food has baseline pain even when she does not eat briefly the pain went into her left arm but is now gone was nauseous yesterday and vomited twice vomited twice this morning after trying to eat cream of wheat the vomit looked like coffee grounds last real meal was days ago other symptoms include lightheadedness at baseline not only when exerting herself denies cough sob headache vision changes diarrhea constipation in the ed initial vs were ra exam notable for no scleral icterus fecal occult negative brown stool ecg my read sinus rhythm 1st degree av block no q waves no st t changes concerning for ischemia labs showed wbc h h plt ptt inr cr hco3 with ag k on repeat without intervention lactate imaging showed ct a p w contrast no evidence of pneumoperitoneum or other findings to suggest esophageal perforation although this examination is limited without oral contrast no other acute findings within the chest abdomen or pelvis cm linear radiodensity within the stomach indeterminate possibly an endoscopic clip cirrhotic appearing liver without focal liver lesions sequela of portal hypertension include splenomegaly and varices consults liver consulted keep npo admit to medicine gastrografin study in am gi will follow patient received ivf and morphine 4mg x2 for pain transfer vs were ra on arrival to the floor patient reports having the same abdominal pain but denies vision changes headaches chest pain arm pain nausea vomiting new weakness or new sensation changes past medical history niddm cirrhosis class a variceal bleed at osh presented with coffee ground emesis and melena and was found to have grade ii varices banded x3 also with gastric erosion noted with contact bleeding that required clipping per report no description of high risk stigmatata or active bleeding no biopsies taken chronic back pain after a fall years ago is on disability and ambulates with a walker cad she was seen at with chest pain and underwent exercise stress test she was told she has angina and was given prn nitro asthma anxiety gerd prior obesity osteoporosis gout appendectomy hysterectomy c s x3 social history family history mother heart attackx3 father stroke brother who died secondary to alcohol cirrhosis brother with cancer daughter thinks she may have fatty liver disease physical exam admission physical exam vs reviewed in general appears to be in distress no respiratory distress heent at nc eomi perrl anicteric sclera pink conjunctiva mmm neck supple heart rrr s1 s2 no murmurs gallops or rubs lungs ctab no wheezes rales rhonchi breathing comfortably without use of accessory muscles abdomen tender diffusely to light palpation even with stethoscope mostly focused in epigastric region extremities no cyanosis clubbing or edema pulses dp pulses bilaterally neuro a ox3 moving all extremities with purpose skin warm and well perfused no excoriations or lesions no rashes discharge physical exam vs hr data last updated temp tm bp hr rr o2 sat o2 delivery ra general sitting up in bed in no acute distress heent at nc eomi perrl anicteric sclera mmm poor dentition heart rrr s1 s2 no murmurs gallops or rubs lungs ctab no wheezes rales rhonchi breathing comfortably without use of accessory muscles abdomen abdomen soft nondistended mild tenderness in epigastric area no guarding or rebound no organomegaly extremities no cyanosis clubbing or edema pulses dp pulses bilaterally neuro a ox3 moving all extremities with purpose and ambulating without difficulty skin warm and well perfused no excoriations or lesions no rashes pertinent results admission labs 15pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 15pm neuts monos eos basos im absneut abslymp absmono abseos absbaso 15pm ptt 15pm albumin 15pm ctropnt 15pm lipase 15pm alt sgpt ast sgot alk phos tot bili 15pm glucose urea n creat sodium potassium chloride total co2 anion gap 24pm lactate k micro blood cultures from ngtd imaging ct c a p with contrast no evidence of pneumoperitoneum pneumomediastinum or other findings to suggest esophageal perforation although this examination is limited without oral contrast no other acute findings within the chest abdomen or pelvis cm linear radiodensity within the stomach possibly an endoscopic clip cirrhotic appearing liver without focal liver lesions sequela of portal hypertension include splenomegaly and varices esophagram with gastrografin no esophageal perforation subtle fusiform outpouching in the proximal to mid esophagus without evidence of mucosal disruption or concerning lesion mild spontaneous gastroesophageal reflux chest x ray findings images demonstrate advancement of a dobhoff into the stomach on the final image the tip projects over the distal stomach there is no focal consolidation pleural effusion or pneumothorax identified the size of the cardiomediastinal silhouette is within normal limits impression the second and final image demonstrates the tip of the dobhoff to project over the stomach discharge labs 15am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 15am blood glucose urean creat na k cl hco3 angap 15am blood calcium phos mg brief hospital course ms is a year old woman with a h o htn niddm nash cirrhosis class a complicated by ascites and esophageal variceal bleeding in s p banding x with recent admission for esophageal stricture s p dilation on who presented with recurrent abdominal pain and dysphagia acute issues dysphagia nausea abdominal pain severe protein calorie malnutrition has had multiple hospitalizations for this complaint of abdominal pain and dysphagia to solids most recently discharged on given esophageal dilation on pain initially concerning for perforation although ct a p and gastrografin study were both negative for perforation other possibilities include gastroparesis for which she was started on metoclopramide during her last admission vs functional gi disturbance low concern for pud given no ulcers seen on most recent egd on she was started on carafate hyacosamine bid ppi and viscous lidocaine per gi recommendations she was given bid reglan and prn ativan for nausea zofran held i s o borderline qtc prolongation given her poor po intake despite better symptom control a dobhoff was placed on for initiation of tube feeds for nutritional support she was unable to tolerate dobhoff so it was removed at patient request on after discussion with gi a g tube was felt to be high risk she was able to increase her po intake to frappes day per nutrition she would require about frappes per day to meet her nutritional requirements anxiety she was noted to have significant anxiety which seemed to trigger drive her nausea she was started on celexa and low dose ativan to help with nausea prolonged qtc patient noted to have prolonged qtc attempted to discontinue home reglan with worsening of nausea despite initiation of ativan for nausea qtc monitored throughout hospitalization and was prior to discharge patient should have qtc monitored as an outpatient and consider weaning reglan coffee ground emesis patient states she had coffee ground emesis x2 prior to admission concerning for upper gi bleed no recurrence of coffee ground emesis since admission and no melena or hematochezia on most recent egd on no varices although prior history of varices suspect slight mucosal tearing after recent esophageal dilation she was continued on bid ppi while inpatient and her hgb remained stable nash cirrhosis childs a meld na on admission history of ascites and esophageal variceal bleeding s p banding x3 no prior history of he no evidence of decompensation on examination her home spironolactone and lasix were held in the setting of inability to tolerate pos and on discharge it should be resumed when she is able to reliably take in po intake anion gap acidosis resolved lactate elevated on admission resolved with fluids chronic issues niddm held home metformin and continued hiss back pain chronic lumbar and cervical pain previously with narcotics contract at however with last script for narcotics hydrocodone acet tid in since then has been prescribed d and 3d prescriptions no recent narcotic script she was not discharged with narcotics transitional issues discharge weight kg please continue to monitor weight regularly please continue to encourage patient to complete nutritional supplements frappes per day and as much additional food intake as tolerated please wean ativan as tolerated patient should have qtc monitored as an outpatient and consider weaning reglan please repeat ekg to monitor qtc on at outpatient pcp consider uptitration of celexa in weeks as needed antiemetic abdominal pain regimen carafate hyacosamine bid ppi viscous lidocaine ativan reglan bid emetrol was not available in house but patient will be provided with prescription to trial at home home spironolactone and furosemide held given irregular po intake home cyclobenzaprine and narcotic discontinued caution if resuming opioid medications given initiation of benzodiazepine as above should only be done with close physician contact medications on admission the preadmission medication list is accurate and complete albuterol inhaler puff ih q4h prn wheezing furosemide mg po daily hydrocodone acetaminophen 5mg 325mg tab po q8h prn pain severe multivitamins tab po daily omeprazole mg po daily polyethylene glycol g po daily senna mg po bid spironolactone mg po bid acetaminophen mg po q12h prn pain mild metformin glucophage mg po bid cyclobenzaprine mg po tid prn muscle spasm metoclopramide mg po bid discharge medications citalopram mg po daily rx citalopram mg tablet s by mouth daily disp tablet refills emetrol phosphorated carbohydrate ml oral qachs prn rx phosphorated carbohydrate ml by mouth qachs prn disp bottle refills hyoscyamine mg sl qid rx hyoscyamine sulfate mg tablet s sublingually four times a day disp tablet refills lidocaine viscous ml po tid prn odynophagia rx lidocaine hcl lidocaine viscous ml tid prn refills lorazepam mg po q6h prn nausea or severe anxiety rx lorazepam mg tablet by mouth q6h prn disp tablet refills simethicone mg po qid prn abd pain rx simethicone gas relief mg tablet by mouth q6h prn disp tablet refills sucralfate gm po qid rx sucralfate gram tablet s by mouth four times a day disp tablet refills omeprazole mg po bid acetaminophen mg po q12h prn pain mild albuterol inhaler puff ih q4h prn wheezing metformin glucophage mg po bid metoclopramide mg po bid multivitamins tab po daily polyethylene glycol g po daily senna mg po bid held cyclobenzaprine mg po tid prn muscle spasm this medication was held do not restart cyclobenzaprine until speaking with your primary care physician held furosemide mg po daily this medication was held do not restart furosemide until speaking with your primary care physician held spironolactone mg po bid this medication was held do not restart spironolactone until speaking with your primary care physician home discharge diagnosis abdominal pain severe protein calorie malnutrition nash cirrhosis anxiety 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 to participate in your care why was i admitted to the hospital you had worsening stomach pain nausea and trouble swallowing after your recent dilation of your esophagus you had also had episodes of vomiting that looked like coffee grounds what happened while i was here you had a ct scan of your chest abdomen and pelvis which did not show any perforation small hole in your esophagus you had another study called a barium swallow which similarly did not show any perforation you continued to have stomach pain and nausea so the gi doctors recommended starting a new medication called hyosciamine you were given zofran and ativan for nausea we recommended that you try a liquid soft food diet unfortunately you continued to feel sick and throw up after eating even on this modified diet since we were concerned that you were malnourished we placed an ng tube and started tube feeds to help you get better nutrition you were unable to tolerate the ng tube however you were able to drink about nutritional supplements a day what should i do when i get home please continue to eat drink as much as tolerated you should drink nutritional supplements frappes per day to meet your caloric needs please follow up with your appointments as below we wish you the best sincerely your care team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies clindamycin naproxen sulfa sulfonamide antibiotics e mycin ibuprofen attending chief complaint abdominal pain major surgical or invasive procedure none history of present illness year old woman with a h o htn niddm cirrhosis class a complicated by ascites and esophageal variceal bleeding in s p banding x with recent admission for esophageal stricture s p dilation on who presented with abdominal pain and nausea she reports that her pain has been increasing in severity at home over the past couple of weeks it is usually sharp stabbing and periumbilical and always present but waxes and wanes and is exacerbated by movement like bending over or turning onto her side today she reports a few days of abdominal pain and she points in a line midline from the epigastrum to suprapubic area this is worse than her normal pain she has not had vomiting her stools are watery and have been so since prepping for her colonoscopy that she says was about days ago apparently done at the patient reports she was not told it was abnormal she denies recent sick contacts new food or travel of note she was discharged from on during that hospitalization it was noted she has had multiple hospitalizations for abdominal pain and dysphagia to solids she had esophageal dilation on it was possible she has a diagnosis of gastroparesis she was unable to tolerate a dobhoff so it was removed at her request she was given bid reglan and prn ativan for nausea zofran held i s o borderline qtc prolongation after discussion with gi a g tube was felt to be high risk she was able to increase her po intake to frappes day per nutrition she would require about frappes per day to meet her nutritional requirements she was noted to have significant anxiety which seemed to trigger drive her nausea she was started on celexa and low dose ativan to help with nausea in ed initial vs f bp hr rr ra exam extremely poor dentition loose necrotic appearing teeth rrr no murmurs abd soft with tenderness to palpation at midline from epigastrum to suprapubic area labs significant for wbc hgb plts inr lactate lfts within normal limits chem within normal limits with cr ua with few bacteria trace leuks patient was given started on levophed per trial ctx flagyl mg iv morphine ed reported they were unable to continue to give fluids as patient is enrolled in a study that prevents further administration of iv fluids imaging notable for ct a p wall thickening with some pericolonic fat stranding involving the sigmoid and rectum could reflect mild short segment colitis if clinically appropriate cirrhotic liver with splenomegaly and trace ascites keeping with portal hypertension on arrival to the micu the patient appears comfortable and states her pain is better controlled with morphine she reports taking only tylenol at home she confirms the above history she specifically denies lightheadedness nausea vomiting at this time diarrhea dysuria lower extremity swelling past medical history niddm cirrhosis cph class a variceal bleed at osh presented with coffee ground emesis and melena and was found to have grade ii varices banded x3 also with gastric erosion noted with contact bleeding that required clipping per report no description of high risk stigmatata or active bleeding no biopsies taken chronic back pain after a fall years ago is on disability and ambulates with a walker cad she was seen at with chest pain and underwent exercise stress test she was told she has angina and was given prn nitro asthma anxiety gerd prior obesity osteoporosis gout appendectomy hysterectomy c s x3 social history family history mother heart attackx3 father stroke brother who died secondary to alcohol cirrhosis brother with cancer daughter thinks she may have fatty liver disease physical exam on admission general alert oriented no acute distress no asterixis heent sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs clear to auscultation bilaterally no wheezes rales rhonchi cv regular rate and rhythm normal s1 s2 no murmurs rubs gallops abd soft flinches to palpation in the central and suprapubic llq area bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema skin no rash neuro no asterixis no tremor moving all extremities spontaneously on discharge vitals t98 po bp l lying hr75 rr17 o2sat ra general alert interactive eyes sclera anicteric eom perrl heent mmm poor dentition with decaying bottom teeth several missing teeth resp breathing comfortably on room air clear to auscultation bilaterally cv regular rate and rhythm systolic murmur best heard at left upper sternal border gi non distended bowel sounds present mildly tender to palpation in epigastrium tender to deep palpation in llq otherwise abdomen soft and nontender no rebound tenderness or guarding liver not palpated no splenomegaly appreciated msk warm well perfused pulses no clubbing cyanosis or edema skin no rashes no palmar erythema no spider angiomata non tender nodule in left palm neuro a ox3 cns2 intact walking hall with normal gait pertinent results admission labs 41pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 41pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 41pm blood ptt 41pm blood glucose urean creat na k cl hco3 angap 41pm blood alt ast alkphos totbili 41pm blood lipase 41pm blood albumin discharge labs 05am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 05am blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 05am blood ptt 05am blood glucose urean creat na k cl hco3 angap 05am blood alt ast alkphos totbili 05am blood calcium phos mg studies reports ct abd pelvis w contrast examination ct abdomen and pelvis technique single phase split bolus contrast mdct axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique oral contrast was not administered coronal and sagittal reformations were performed and reviewed on pacs dose acquisition sequence stationary acquisition s cm ctdivol mgy body dlp mgy cm spiral acquisition s cm ctdivol mgy body dlp mgy cm total dlp body mgy cm comparison ct abdomen and pelvis findings lower chest with the exception of bibasilar atelectasis the visualized lung fields are within normal limits there is no evidence of pleural or pericardial effusion abdomen hepatobiliary the liver demonstrates a nodular contour consistent with cirrhosis it is diffusely hypoattenuating with respect to the spleen consistent with steatosis there is no evidence of focal lesions there is no evidence of intrahepatic or extrahepatic biliary dilatation the gallbladder is within normal limits pancreas the pancreas is somewhat atrophic with has normal attenuation throughout without evidence of focal lesions or pancreatic ductal dilatation there is no peripancreatic stranding spleen the spleen is enlarged measuring up to cm 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 bilateral renal cysts are unchanged there is no evidence of suspicious renal lesions or hydronephrosis there is no perinephric abnormality gastrointestinal the stomach is unremarkable small bowel loops demonstrate normal caliber wall thickness and enhancement throughout the is filled with dense fluid there is wall edema with mild mucosal hyperenhancement and pericolonic fat stranding involving the sigmoid which could reflect short segment proctocolitis no fluid collection or free air diverticulosis is noted the appendix contains dense material which could be calcification or previously ingested inspissated contrast no evidence of periappendiceal fat stranding pelvis the urinary bladder and distal ureters are unremarkable trace free fluid in the pelvis reproductive organs the uterus is not seen no adnexal abnormality is detected 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 bones there is no evidence of worrisome osseous lesions or acute fracture mild to moderate degenerative changes of the lumbar spine are noted soft tissues the abdominal and pelvic wall is within normal limits impression wall thickening with some pericolonic fat stranding involving the sigmoid and rectum could reflect mild short segment colitis if clinically appropriate cirrhotic liver with splenomegaly and trace ascites keeping with portal hypertension colonscopy report sturdy poor prep hard stool noted at rectosigmoid region aborted microbiology am stool consistency not applicable source stool cyclospora stain pending fecal culture pending campylobacter culture final no campylobacter found ova parasites final no ova and parasites seen this test does not reliably detect cryptosporidium cyclospora or microsporidium while most cases of giardia are detected by routine o p the giardia antigen test may enhance detection when organisms are rare fecal culture r o vibrio final no vibrio found cryptosporidium giardia dfa final no cryptosporidium or giardia seen cdiff negative brief hospital course ms is a w pmhx notable for htn t2dm cirrhosis a meld na c b ascites and esophageal variceal bleeding in s p banding x3 recently admitted for esophageal stricture s p dilation who presented for abdominal pain and nausea admitted to the micu for hypotension part of trial w early initiation of peripheral levophed and rapidly weaned off pressors and transferred to medicine for evaluation of abdominal pain inpatient active issues hypotension resolved upon arrival to the ed her vitals were initially stable with sbp 120s she subsequently developed episodes of soft sbp to 90s for which she received l iv fluids and was enrolled in trial with early initiation of peripheral levophed and admitted to the micu her baseline bps appear to be in the 120s were most likely lower than baseline due to hypovolemia secondary to poor po intake in the setting of recent colonoscopy prep and chronic poor nutrition she was quickly weaned from levophed and her blood pressures normalized without any further intervention acute on chronic abdominal pain she reports chronic abdominal pain since and has had multiple admissions for these symptoms without a conclusive diagnosis she was seen by gastroenterology on last admission who felt abdominal pain was most consistent with gastroparesis or abnormal gastric accommodation vs functional gi disorder pain has primarily been in periumbilical region but over last few weeks worsened and migrated to epigastrium no pre post prandial pain a ct on admission revealed short segment colitis but no hepatobiliary pathology ascites or gastric abnormalities to explain her symptoms her abdominal exam was stable during her admission and notable for mild tenderness to palpation in the epigastrium and the left lower quadrant her lactate was within normal limits and her liver function tests were stable throughout her admission of note during recent admission she had an egd notable for stricture which was dilated this admission she denied dysphagia and was able to tolerate liquids and soft foods although she did report epigastric fullness after po intake there was no regurgitation or vomiting patient would benefit from repeat egd to assess for stricture recurrence as outpatient rectosigmoid colitis ct abd pelvis with short segment colitis she had a colonoscopy at on but it was terminated due to poor prep given hard stool in rectosigmoid area her colitis could be consistent with stercoral colitis given stool burden noted on ct and in the context of colonoscopy irritation there was also concern for infection given soft blood pressures initially on admission and she was started on a day course of cipro flagyl of note she was c diff negative this admission and her stool cultures were pending at the time of discharge but no growth at discharge patient should have repeat colonoscopy at outpatient pancytopenia platelet nadir this admission on discharge has splenomegaly and known cirrhosis hemoglobin this admission from recent baseline wbc count nadir from usual baseline felt most most likely a combination of cirrhosis and poor nutrition effect of infection would recommended repeat outpatient cbc at repeat pcp visit and perhaps referral to outpatient hematology chronic issues nash cirrhosis meld no evidence of acute decompensation exam not concerning for encephalopathy ascites or fluid overload lasix and spironolactone were held on admission in setting of hypotension her renal function coagulation studies and lfts were remained at baseline throughout admission type diabetes mellitus her home metformin was held during the admission she should restart upon discharge gerd she was continued on omeprazole mg po bid while inpatient transitional issues antibiotics discharge regimen day course of cipro flagyl day on leukopenia nadir wbc please repeat cbc at next pcp visit to ensure improvement stability would consider referral to hematology as outpatient if remains leukopenic patient would benefit from repeat egd and colonoscopy outpatient colonoscopy was terminated due to poor prep repeat egd would be to ensure no recurrence of stricture that was dilated at on and to evaluate source of epigastric fullness discomfort abdominal pain she should follow up with her outpatient gi specialist for further management she will contact her outpatient gi specialist for follow up cirrhosis patient has missed several outpatient appointments with hepatologist dr instructed to call him for outpatient follow up of cirrhosis stool cultures pending but no growth on discharge narcotics patient reported she gets narcotics filled regularly by primary care provider however this is not factually correct when checked she has been noted to have had several different short term narcotics prescriptions from several providers over past year was not provided rx for narcotics upon discharge narcotics should be ideally avoided in setting of chronic abdominal pain constipation and concern for slowed gi motility minutes was spent on discharge planning care coordination and patient care medications on admission the preadmission medication list is accurate and complete metoclopramide mg po bid hyoscyamine mg sl qid sucralfate gm po qid albuterol inhaler puff ih q4h prn wheezing furosemide mg po daily metformin glucophage mg po bid multivitamins tab po daily omeprazole mg po bid emetrol phosphorated carbohydrate ml oral qachs prn oxycodone immediate release mg po q6h prn pain severe discharge medications ciprofloxacin hcl mg po q12h rx ciprofloxacin hcl mg tablet s by mouth every hours disp tablet refills metronidazole mg po q8h rx metronidazole mg tablet s by mouth every hours disp tablet refills polyethylene glycol g po daily prn constipation senna mg po bid rx sennosides senna laxative mg tablet by mouth twice daily disp tablet refills simethicone mg po qid prn abd pain rx simethicone gas relief mg capsule by mouth twice daily as needed for gas pain disp capsule refills albuterol inhaler puff ih q4h prn wheezing emetrol phosphorated carbohydrate ml oral qachs prn hyoscyamine mg sl qid metformin glucophage mg po bid metoclopramide mg po bid multivitamins tab po daily omeprazole mg po bid sucralfate gm po qid held furosemide mg po daily this medication was held do not restart furosemide until you are told to by a doctor discharge disposition home discharge diagnosis primary diagnosis acute on chronic abdominal pain secondary diagnosis rectosigmoid colitis hypotension resolved 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 for abdominal pain and low blood pressures what happened to you your blood pressures improved with fluids you were given antibiotics to treat a possible infection in your lower colitis your upper belly pain was stable and typical when compared to your usual belly pain imaging of your belly did not show anything to explain the cause of your pain what should you do after you leave the hospital please finish the antibiotic pills fill your prescription at a local pharmacy please take your other medicines as prescribed please see your primary care doctor below as scheduled please follow up with your gastroenterology doctor in like you mentioned you planned on doing please follow up with your liver doctor please eat small meals more frequently instead of larger meals especially when your stomach is bothering you please ensure you are well hydrated and try to have regular bowel movements please seek care if you are unable to eat and drink by mouth have severe change in your belly pain fevers black stool or blood in your stool we wish you the best and hope that you feel better your care team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies clindamycin naproxen sulfa sulfonamide antibiotics e mycin ibuprofen attending chief complaint abdominal pain major surgical or invasive procedure none history of present illness ms is a year old woman with a h o htn niddm cirrhosis class a complicated by ascites and esophageal variceal bleeding in s p banding x with recent admission for esophageal stricture s p dilation on who presented with abdominal pain patient was recently admitted for abdominal pain a ct on admission revealed short segment colitis but no hepatobiliary pathology ascites or gastric abnormalities to explain her symptoms she was discharged with a course of cipro and flagyl she also reports another admission to discharged with an infection in her she was discharged on augmentin but has been unable to take any of her medications due to nausea and pain she reports feeling weak and tired and is having trouble walking she is having sharp diffuse abdominal pain worse on the left side it is constant but fluctuates in intensity her last bowel movement was this morning and she reports it was all water she reports some occasional nausea she denies fever chest pain sob cough vomiting brbpr melena or dysuria past medical history niddm cirrhosis class a variceal bleed at presented with coffee ground emesis and melena and was found to have grade ii varices banded x3 also with gastric erosion noted with contact bleeding that required clipping per report no description of high risk stigmatata or active bleeding no biopsies taken chronic back pain after a fall years ago is on disability and ambulates with a walker cad she was seen at with chest pain and underwent exercise stress test she was told she has angina and was given prn nitro asthma anxiety gerd prior obesity osteoporosis gout appendectomy hysterectomy c s x3 social history family history mother heart attackx3 father stroke brother who died secondary to alcohol cirrhosis brother with cancer daughter thinks she may have fatty liver disease physical exam admission physical exam vs reviewed in omr gen nad interactive alert heent mmm poor dentition with decaying bottom teeth several missing teeth sclera anicteric eom perrl resp breathing comfortably on room air clear to auscultation bilaterally cv regular rate and rhythm systolic murmur best heard at left upper sternal border gi non distended bowel sounds present mildly tender to palpation in epigastrium tender to deep palpation in llq otherwise abdomen soft and nontender no rebound tenderness or guarding liver not palpated no splenomegaly appreciated msk warm well perfused pulses no clubbing cyanosis or edema skin no rashes no palmar erythema no spider angiomata non tender nodule in left palm neuro a ox3 moving extremities w purpose pertinent results admission labs 30pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 30pm blood plt 30pm blood glucose urean creat na k cl hco3 angap 30pm blood estgfr using this 30pm blood alt ast alkphos totbili 30pm blood lipase 30pm blood albumin 53pm blood lactate discharge labs 20am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 20am blood plt 20am blood ptt 20am blood glucose urean creat na k cl hco3 angap 20am blood alt ast ld ldh alkphos totbili 20am blood ctropnt 20am blood albumin calcium phos mg imaging ct abd pelvis impression sigmoid diverticulosis with essentially complete resolution of previously noted pericolonic fat stranding and hyperenhancement of the sigmoid no evidence of acute intra abdominal or intrapelvic process to explain the patient s current symptoms cirrhotic liver with splenomegaly brief hospital course year old woman with a h o htn niddm class a complicated by ascites and esophageal variceal bleeding in s p banding x with recent admission for esophageal stricture s p dilation on who presented with recurrent abdominal pain she left prior to the day team s formal evaluation against medical advise acute issues acute on chronic abdominal pain multiple hospital visits for this complaint with most recent discharge on from sturdy hosptial prior ct showing evidence of short segment colitis as a potential etiology treated with cipro and flagyl recent osh admission also with persistent colitis as per patient discharged on augmentin ct a p on this admission without any abnormalities to explain the patient s symptoms no fevers leukocytosis to indicate infectious process most likely etiology likely an acute exacerbation of patient s gastroparesis vs residual pain from prior bout of colitis during an earlier admission started on reglan with only minimal improvement in symptoms as per patient low suspicion for acs given unremarkable ekg on the morning of prior to the patient s evaluation she refused tylenol for pain and then asked to leave against medical advise as she didn t want to sit in the hospital in pain when she could just do it at home she was counseled on the risk of leaving prior to full examination including worsening infection or missing a severe issue with her bowels she voice understanding of these concerns and able to repeat them back she continued to insist on leaving she called her daughter for a ride overall low suspicion with initial work up for life threatening condition she was continued on home hyoscyamine mg metoclopramide mg po ng bid simethicone mg po ng qid prn abd pain omeprazole 40mg bid and augmentin her reglan was held due to long qtc and no repeat ekg to verify cirrhosis childs a history of ascites and esophageal variceal bleeding s p banding x3 no prior history of he no evidence of decompensation on examination on admission hepatology did not suspect underlying cirrhosis as a cause gap acidosis lactate elevated also likely ketosis starvation s p 1l ns in the ed she left against medical advise prior to further work up and evaluation chronic issues niddm held home metformin and start iss back pain chronic lumbar and cervical pain previously on opioid contract at but has not been filled since shows recent filled rx for oxycodone from providers in last months so discontinued narcotics during prior admission narcotics were not used for pain control while in house type diabetes mellitus last a1c on on metformin mg bid at home though this had been discontinued during previous sturdy admission to avoid stomach upset gerd omeprazole mg po bid transitional issues left against medical advice should try to attend previously scheduled gi appointment with dr colonoscopy encouraged to schedule and attend pcp on future admissions would check prior to prescribing narcotic medications code full presumed contact daughter medications on admission the preadmission medication list may be inaccurate and requires futher investigation albuterol inhaler puff ih q4h prn wheezing hyoscyamine mg sl qid metoclopramide mg po bid omeprazole mg po bid sucralfate gm po qid multivitamins tab po daily metformin glucophage mg po bid furosemide mg po daily emetrol phosphorated carbohydrate ml oral qachs prn simethicone mg po qid prn abd pain senna mg po bid polyethylene glycol g po daily prn constipation amoxicillin clavulanic acid mg po q12h discharge medications albuterol inhaler puff ih q4h prn wheezing amoxicillin clavulanic acid mg po q12h emetrol phosphorated carbohydrate ml oral qachs prn furosemide mg po daily hyoscyamine mg sl qid multivitamins tab po daily omeprazole mg po bid polyethylene glycol g po daily prn constipation senna mg po bid simethicone mg po qid prn abd pain sucralfate gm po qid held metformin glucophage mg po bid this medication was held do not restart metformin glucophage until you follow up with your pcp held metoclopramide mg po bid this medication was held do not restart metoclopramide until you see your pcp home discharge diagnosis primary abdominal pain secondary cirrhosis niddm discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms you were here because you were having abdominal pain while you were here you had an imaging study of your stomach called a ct scan which showed improvement in the inflammation in your unfortunately you left against medical advice before we were able to evaluate your abdominal pain we had a detailed conversation about the risks of leaving ama you verbalized understanding and wished to leave anyway when you leave please continue your previously prescribed antibiotics if you are not able to eat or drink please come back to the er please attend your previously scheduled gi appointment with dr we wish you the best of luck your care team followup instructions

name unit no admission date discharge date date of birth sex m service cardiothoracic allergies penicillins atorvastatin attending chief complaint chest pain major surgical or invasive procedure coronary artery bypass grafting x1 with the left internal mammary artery to the left anterior descending artery history of present illness year old male with known coronary artery disease and s p stents in the past who originally presented to with episodes of exertional angina that escalated to rest he had an episode of pressure in his jaw neck and ears while he was exerting himself the event lasted a few minutes but he began to have chest tightness and chest pressure associated with radiation to the neck jaw ears he had an appointment the following morning at where he was ruled out for mi by troponins but due to ekg changes he was sent for a cardiac catheterization which revealed an ostial lad lesion that was positive by fractional flow reserve ffr and a small om he was transferred to to evaluate for pci vs cabg after cardiology at reviewed films it was determined to consult cardiac surgery for surgical revascularization past medical history coronary artery disease hyperlipidemia tobacco use umbilical hernia repair w mesh prior stents ramus bms ramus mid left cx and mid rca s p stenting all patent social history family history maternal grandfather with first mi age father first mi age several uncles developed cad in physical exam pulse resp o2 sat ra b p height weight kg 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 irregular no murmurs appreciated abdomen soft x non distended x non tender x bowel sounds x extremities warm x well perfused x no edema varicosities none x neuro grossly intact x pulses femoral right p left p dp right p left p right p left p radial right p left p carotid bruit right left pertinent results admission labs 15am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 15am blood ptt 15am blood glucose urean creat na k cl hco3 angap 35am blood alt ast alkphos totbili 15am blood calcium phos mg 15am blood hba1c eag studies imaging cardiac cath the coronary circulation is right dominant left main normal ostial lad there was a discrete stenosis circumflex angiography showed minor luminal irregularities obtuse marginal the vessel was small sized there was a discrete stenosis at the ostium of the vessel segment proximal ramus intermedius there was a diffuse stenosis at the site of a prior stent mid rca there was a stenosis at the site of a prior stent in a second lesion there was a tubular stenosis lesion intervention a percutaneous intervention was performed on the lesion in the proximal lad following intervention there was a residual stenosis this was an acc aha non high risk lesion for intervention there was timi flow before the procedure and timi flow after the procedure there was no acute vessel closure there was no perforation there was no dissection tte the left atrium is elongated left ventricular wall thicknesses and cavity size are normal there is mild regional left ventricular systolic dysfunction with focal hypokinesis of the basal to mid inferior wall the remaining segments contract normally lvef tissue doppler imaging suggests a normal left ventricular filling pressure pcwp 12mmhg there is a mild resting left ventricular outflow tract obstruction there is no ventricular septal defect the right ventricular cavity is mildly dilated the diameters of aorta at the sinus ascending and arch levels are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are structurally normal there is no mitral valve prolapse trivial mitral regurgitation is seen the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression suboptimal image quality regional left ventricular systolic dysfunction c w cad mild right ventricular cavity dilation rv function difficult to assess given limited acoustic windows discharge labs 05am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 05am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 05am blood ptt 05am blood glucose urean creat na k cl hco3 angap 05am blood glucose urean creat na k cl hco3 angap 05am blood mg conclusions pre bypass the left atrium is normal in size no mass thrombus is seen in the left atrium or left atrial appendage no atrial septal defect is seen by 2d or color doppler left ventricular wall thickness cavity size and global systolic function are normal lvef the right ventricular free wall is hypertrophied the right ventricular cavity is mildly dilated with normal free wall contractility the aortic valve leaflets are mildly thickened but aortic stenosis is not present trace aortic regurgitation is seen the mitral valve leaflets are structurally normal mild mitral regurgitation is seen there is an anterior space which most likely represents a prominent fat pad post bypass the patient is in sinus rhythm and receiving a phenylephrine infusion biventricular function remains preserved valvular function is unchanged the thoracic aorta is intact following decannulation brief hospital course mr was transferred from outside hospital after cardiac cath revealed an ostial lad lesion upon admission he received medical management while undergoing surgical work up and awaiting plavix wash out on he was brought to the operating room where he underwent a coronary artery bypass graft x please see operative note for surgical details following surgery he was transferred to the cvicu for invasive monitoring in stable condition later this day he was weaned from sedation awoke neurologically intact and extubated beta blocker was initiated and the patient was gently diuresed toward the preoperative weight the patient was transferred to the telemetry floor for further recovery chest tubes and pacing wires were discontinued without complication the patient was evaluated by the physical therapy service for assistance with strength and mobility he had significant pain post operatively and was managed with dilaudid neurontin and toradol he is advised to continue ibuprofen for week as well as a lidocaine patch for shoulder pain he developed drainage from the superior sternal pole he will be discharged with swabs daily dressing changes and an early wound check by the time of discharge on pod the patient was ambulating freely the wound was healing and pain was controlled with oral analgesics the patient was discharged home in good condition with appropriate follow up instructions medications on admission the preadmission medication list is accurate and complete clopidogrel mg po daily rosuvastatin calcium mg po qpm aspirin mg po daily fexofenadine mg po bid discharge medications docusate sodium mg po bid rx docusate sodium mg capsule s by mouth twice a day disp capsule refills furosemide mg po daily duration days rx furosemide mg tablet s by mouth daily disp tablet refills gabapentin mg po tid rx gabapentin mg capsule s by mouth three times a day disp capsule refills hydromorphone dilaudid mg po q3h prn pain severe rx hydromorphone mg tablet s by mouth every four hours disp tablet refills ibuprofen mg po q8h duration days rx ibuprofen mg tablet s by mouth every eight hours disp tablet refills lidocaine patch ptch td qpm rx lidocaine patch qpm disp patch refills metoprolol tartrate mg po tid rx metoprolol tartrate mg tablet s by mouth three times a day disp tablet refills potassium chloride meq po daily duration days rx potassium chloride meq tablet s by mouth daily disp tablet refills ranitidine mg po bid rx ranitidine hcl mg tablet s by mouth twice a day disp tablet refills senna mg po bid rx sennosides senna mg by mouth twice a day disp tablet refills aspirin mg po daily clopidogrel mg po daily fexofenadine mg po bid rosuvastatin calcium mg po qpm discharge disposition home with service facility discharge diagnosis coronary artery disease s p coronary artery bypass graft x past medical history hyperlipidemia tobacco use umbilical hernia repair w mesh prior stents ramus bms ramus mid left cx and mid rca s p stenting all patent discharge condition alert and oriented x3 non focal ambulating with steady gait incisional pain managed with dilaudid incisions sternal healing well no erythema or drainage leg healing well no erythema or drainage edema trace discharge instructions please shower daily including washing incisions gently with mild soap no baths or swimming until cleared by surgeon look at your incisions daily for redness or drainage please no lotions cream powder or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature these should be written down on the chart no driving for approximately one month and while taking narcotics will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than pounds for weeks please call with any questions or concerns please call cardiac surgery office with any questions or concerns answering service will contact on call person during off hours followup instructions

name unit no admission date discharge date date of birth sex m service cardiothoracic allergies penicillins atorvastatin attending chief complaint chest pain doe major surgical or invasive procedure major surgical or invasive procedures coronary artery bypass grafting x1 with the left internal mammary artery to the left anterior descending artery history of present illness mr is a with cad s p pcix3 and recent cabg x1 lima lad on who presents with recurrent chest pain and shortness of breath his post operative course was uncomplicated and he was discharge home on with services he had been doing well at home until yesterday when he had one episode of mild chest pain lasting a few minutes he was asymptomatic until this evening when he again started to have recurrent chest pain and shortness of breath relieved with sl nitroglycerin he noted radiation of pain to the left arm and jaw given these symptoms his wife brought him to the hospital for further evaluation of note he has been hesitant in taking his pain medications given concerns for addiction on arrival to the ed he had no chest pain complaints ekg was obtained which showed inverted t waves in i avl v2 v6 given these findings cardiac surgery was consulted for further evaluation past medical history coronary artery disease cabg x1 hyperlipidemia tobacco use umbilical hernia repair w mesh prior stents ramus bms ramus mid left cx and mid rca s p stenting all patent social history family history maternal grandfather with first mi age father first mi age several uncles developed cad in physical exam physical exam vitals ra height n a weight n a general skin dry x intact x heent perrla x eomi neck supple x full rom chest lungs clear bilaterally x midline sternotomy and chest tube incisions well healing no surrounding erythema no drainage heart rrr x irregular murmur grade abdomen soft x non distended x non tender x bowel sounds extremities warm x well perfused edema varicosities none neuro grossly intact x pulses femoral right p left p dp right p left p right p left p radial right p left p pertinent results 10am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 06pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 10am blood plt 10am blood glucose urean creat na k cl hco3 angap 06pm blood glucose urean creat na k cl hco3 angap 10am blood ck mb ctropnt 06pm blood ctropnt echo the left atrium is normal in size the left atrial volume index is normal left ventricular wall thickness cavity size and regional global systolic function are normal lvef tissue doppler imaging suggests an increased left ventricular filling pressure pcwp 18mmhg right ventricular chamber size and free wall motion are normal there is abnormal septal motion bounce and shudder suggestive of pericardial constriction presystolic ejection across the pulmonic valve is present suggestive of constriction the aortic valve leaflets 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 left ventricular inflow pattern suggests a restrictive filling abnormality with elevated left atrial pressure the pulmonary artery systolic pressure could not be determined there is no pericardial effusion compared with the prior study images reviewed of findings are now suggestive of early pericardial constriction nuclear ett findings left ventricular cavity size is normal rest and stress perfusion images reveal a fixed perfusion defect in the basilar portion of the inferior likely representing attenuation otherwise uniform tracer uptake throughout the left ventricular myocardium gated images reveal normal wall motion including the basilar portion of the interior wall the calculated left ventricular ejection fraction is impression normal cardiac perfusion study normal left ventricular cavity size and ejection fraction brief hospital course with cad s p pcix3 and recent cabg x1 lima lad on who presents with recurrent chest pain and shortness of breath on arrival to the ed patient s symptoms had completely resolved ekg was obtained which showed new inverted t waves initial troponin level and repeat he underwent an echo on that demonstrates constrictive physiology cardiology has been consulted and a stress test has been ordered per their recommendation his stress test was negative for ischemia and dr spoke to the pt s cardiologist dr felt the patient could go home on and see him in the office in follow up medications on admission the preadmission medication list is accurate and complete aspirin mg po daily clopidogrel mg po daily fexofenadine mg po bid rosuvastatin calcium mg po qpm hydromorphone dilaudid mg po q3h prn pain severe metoprolol tartrate mg po tid lidocaine patch ptch td qpm ranitidine mg po bid docusate sodium mg po bid discharge medications acetaminophen mg po q6h prn pain mild isosorbide mononitrate extended release mg po daily rx isosorbide mononitrate mg tablet s by mouth once a day disp tablet refills nitroglycerin sl mg sl q5min prn chest pain rx nitroglycerin mg tablet s sublingually every mins until x3 until cp resolves if cp continues call disp tablet refills aspirin mg po daily clopidogrel mg po daily docusate sodium mg po bid fexofenadine mg po bid metoprolol tartrate mg po tid ranitidine mg po bid rosuvastatin calcium mg po qpm discharge disposition home with service facility discharge diagnosis coronary artery disease s p coronary artery bypass graft x past medical history hyperlipidemia tobacco use umbilical hernia repair w mesh prior stents ramus bms ramus mid left cx and mid rca s p stenting all patent discharge condition alert and oriented x3 non focal ambulating with steady gait incisions sternal incision clean and dry edema none discharge instructions please shower daily including washing incisions gently with mild soap no baths or swimming until cleared by surgeon look at your incisions daily for redness or drainage please no lotions cream powder or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature these should be written down on the chart no driving for approximately one month and while taking narcotics will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than pounds for weeks please call with any questions or concerns please call cardiac surgery office with any questions or concerns answering service will contact on call person during off hours followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies no known allergies adverse drug reactions attending chief complaint af with rvr major surgical or invasive procedure none history of present illness mr is an y o man with history of cad htn hld who presented today for scheduled outpatient colonoscopy and complained of chest discomfort and was found to have atrial fibrillation with rapid ventricular response the procedure was cancelled and the patient was referred to the ed for further evaluation in the ed initial vital signs were ra labs were notable for bmp cbc within normal limits troponin 01x2 with mb 3x2 studies performed include cxr no acute cardiopulmonary process ekg atrial fibrillation at bpm lad ni std in v4 lvh repeat ekg nsr at bpm biphasic t waves in v3 twi in v4 v6 i avl unchanged from prior patient was given iv metoprolol tartrate mg ivf ns iv metoprolol tartrate mg po metoprolol tartrate mg po aspirin mg iv metoprolol tartrate mg ivf ns ml sc enoxaparin sodium mg after conversion to nsr chest pain resolved per interpreter present who also interpreted in the ed he was at times confused and attempted to walk around the ed on his own upon arrival to the floor initial vitals were ra repeat bp followed by he initially reported headache which he stated was chronic in nature he denied any chest pain shortness of breath or palpations headache resolved after several minutes past medical history cad htn hld retroperitoneal lymphadenopathy of unclear etiology being followed by heme onc gerd urinary incontinence bph s p turp cataracts social history family history relatively unknown estranged from parents since the age of no history of diabetes or of premature coronary disease per dr note physical exam admission exam vitals ra repeat general nad aao x not oriented to year or season or to place heent normocephalic atraumatic eomi neck supple cardiac regular rhythm normal rate no murmurs rubs gallops no vd lungs clear to auscultation bilaterally w appropriate breath sounds appreciated in all fields no wheezes rhonchi or rales resonant to percussion abdomen normal bowels sounds non distended non tender extremities no clubbing cyanosis or edema skin no evidence of ulcers rash or lesions suspicious for malignancy neurologic cn2 intact strength throughout grossly normal sensation discharge exam vitals po ra i os na weight na weight on admission na telemetry sinus general wdwn m in nad oriented x3 mood affect appropriate heent ncat sclera anicteric perrl eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthelasma neck supple with jvp non elevated cardiac rrr normal s1 s2 no m r g no thrills lifts no s3 or s4 lungs ctab no crackles wheezes or rhonchi abdomen soft ntnd no hsm or tenderness extremities no c c e skin no stasis dermatitis ulcers scars or xanthomas pertinent results admission labs 35am wbc rbc hgb hct mcv mch mchc rdw rdwsd 35am neuts monos eos basos im absneut abslymp absmono abseos absbaso 35am calcium phosphate magnesium 35am ck mb 35am ctropnt 35am ck cpk 35am glucose urea n creat sodium potassium chloride total co2 anion gap 24pm tsh tte the left atrial volume index is moderately increased no atrial septal defect is seen by 2d or color doppler there is mild symmetric left ventricular hypertrophy with normal cavity size there is mild symmetric left ventricular hypertrophy with normal cavity size and regional global systolic function lvef the estimated cardiac index is normal 5l min m2 there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the right ventricular free wall thickness is normal the ascending aorta is mildly dilated the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen there is borderline pulmonary artery systolic hypertension there is a trivial physiologic pericardial effusion impression hypertensive heart disease dilated left atrium no significant valve disease cxr no acute cardiopulmonary process discharge labs 46am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 46am blood plt 46am blood glucose urean creat na k cl hco3 angap 46am blood calcium phos mg brief hospital course mr is an y o man with history of cad htn hld who presented today for scheduled outpatient colonoscopy and complained of chest discomfort and was found to have atrial fibrillation with rapid ventricular response atrial fibrillation first known episode now in normal sinus rhythm chadsvasc however does not seem good candidate for anticoagulation given his dementia fall risk and poor social supports no clear triggers not clinically in heart failure no evidence of infection no events on telemetry and remained in sinus rhythm throughout admission his tsh was normal tte showed no significant valvular disease stopped his atenolol and started metoprolol mg bid anticoagulation can be considered per his pcp chest pain cad troponins x2 with flat mb std v4 v6 concerning for underlying cad likely demand in the setting of atrial fibrillation with rvr st depressions now resolved continue asa atorvastatin metoprolol consider outpatient stress dispo per review of outpt records pt does in fact only live with his wife as he reports and children are not involved in his care wife does not speak any and apparently has her own chronic illnesses unclear how patient has been taking care of himself at home or how he get to appointments or takes his medicines consulted and felt no needs pt s son arrived at hospital and felt pt was safe at home they were set up with services clinic was contacted about this and was in agreement with htn continue amlodipine 5mg daily discontinue home atenolol replace with metoprolol hld continue home atorvastatin gerd continue home omeprazole urinary incontinence continue home tamsulosin transitional issues suspect patient is not taking medications when given amlodipine mg and metoprolol mg bid his blood pressure and heart rate were controlled consider outpatient stress test reschedule patient s colonoscopy for his symptoms of bloating anticoagulation for af with chadsvasc per pcp deferred at this time stopped atenolol started metop mg bid full code please obtain health care proxy for this patient medications on admission the preadmission medication list is accurate and complete atenolol mg po daily amlodipine mg po daily vitamin d unit po daily atorvastatin mg po qpm omeprazole mg po daily tamsulosin mg po qhs discharge medications aspirin mg po daily metoprolol tartrate mg po bid rx metoprolol tartrate mg tablet s by mouth twice a day disp tablet refills amlodipine mg po daily atorvastatin mg po qpm omeprazole mg po daily tamsulosin mg po qhs vitamin d unit po daily discharge disposition home with service facility discharge diagnosis primary diagnosis afib with rvr secondary diagnosis htn dementia discharge condition mental status confused sometimes level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr it was a pleasure to take care of you at why did i have to stay in the hospital you had to stay in the hospital because of an abnormal heart rhythm what was done for me you were given medicines to control your heart rate your blood pressure medicine was changed from atenolol to metoprolol for this what should i do when i go home please take your medicines as prescribed please follow up with your regular doctor sincerely your medical team followup instructions

name unit no admission date discharge date date of birth sex f service neurosurgery allergies no known allergies adverse drug reactions attending chief complaint subarachnoid hemorrhage major surgical or invasive procedure diagnostic cerebral angiogram positive for p comm aneurysm angiogram for coiling of pcomm aneurysm history of present illness y o female transferred from osh with whol and imaging showing sah she experienced a sudden onset whol at 30pm this evening while at a funeral she headache was localized to the top of her head and at the base of her skull she also noted a transient episode of hearing loss when the headache started her hearing has returned to normal the headache continued and she was taken to for further evaluation she underwent a ct without contrast at the cha which showed a subarachnoid hemorrhage in the left sylvian fissure and basilar cisterns she was transferred to for further evaluation the patient continues with complaints of a headache which is located at the top of her head and at the base of her skull she also reports bilateral lower facial jaw and tongue numbness and tingling which has improved since the onset of the headache she denies numbness tingling pain and weakness of the upper and lower extremities bilaterally however she does endorse chest pain within the upper portion of the left arm she denies sob nausea vomiting fever chills diplopia dizziness blurred vision or speech language difficulties past medical history htn hyperlipidemia depression arthritis h pylori colon polyp bilateral osteoarthritis of the knees s p right total knee replacement colon polyp gastritis esophagus social history family history no family history of neurologic diease or aneurysms physical exam on discharge speaking limited a ox3 perrl face symmetric no drift mae strength pertinent results cta head w w o c recons study date of am impression mm aneurysm is seen directed laterally at the origin of the left posterior communicating artery and a mm aneurysm is seen directed medially at the origin of left posterior communicating artery diminutive left vertebral artery with termination dominant right vertebral artery otherwise the posterior circulation is unremarkable no significant interval change in the extent of the subarachnoid hemorrhage compared to the prior exam from probable bi frontal small subdural hematomas hypoplastic left transverse sinus likely congenital the remainder the dural venous sinuses are patent intracranial coiling study date of impression successful coiling of a left pcom artery aneurysm compatible with and grade cta head w w o c recons study date of ct head no definite subarachnoid blood identified no new hemorrhage cta head there is no definite evidence of vasospasm of the circle of although of the left mca is possibly slightly more narrow and irregular compared to study from ct neck the a neck vessels are patent without stenosis occlusion or dissection brief hospital course year old female who experienced a sudden onset whol while at a funeral she reported headache which was localized to the top of her head and at the base of her skull she also noted a transient episode of hearing loss when the headache started she was taken to an osh where imaging demonstrated subarachnoid hemorrhage in the left sylvian fissure and basilar cisterns on arrival to a ct cta was performed and demonstrated a mm aneurysm on the posterior communicating artery and a mm aneurysm medially at the origin of left posterior communicating artery she was started on keppra and nimodipine she underwent a diagnostic angiogram which confirmed the pcomm aneursm the patient was taken back to the angio suite on for a coiling of the aneurysm she tolerated the procedure well and was transferred back to the nicu for postop care she developed slight r pronator drift postop which improved she was transferred to on pod tcds were completed on and were negative for vasospasm howevever limited due to poor bone window she remained stable and was transferred to the floor on she was continued on nimodipine and ivf cta was done for vasospasm watch on which did not demonstrate vasospasm she was evaluated by physical therapy and was cleared for safe discharge to home on day of discharge patient was neurologically stable and discharged to home with services in good condition she was set up for home and services family confirmed they would provide home supervision for the first few days after discharge she was given prescription to continue her day course of nimodipine for vasospasm prevention medications on admission unknown discharge medications acetaminophen caff butalbital tab po q4h prn pain severe do not exceed 4g of acetaminophen in hours including from other sources rx butalbital acetaminophen caff mg mg mg tablet s by mouth q4 6h prn headache disp tablet refills aspirin mg po daily rx aspirin mg tablet s by mouth daily disp tablet refills bisacodyl mg po pr daily prn constipation rx bisacodyl mg tablet s by mouth daily prn constipation disp tablet refills levetiracetam mg po bid rx levetiracetam mg tablet s by mouth twice a day disp tablet refills nimodipine mg po q4h rx nimodipine mg capsule s by mouth every four hours disp capsule refills omeprazole mg po daily rx omeprazole mg capsule s by mouth daily disp capsule refills oxycodone immediate release mg po q6h prn pain moderate rx oxycodone mg tablet s by mouth q4 6h prn pain disp tablet refills discharge disposition home with service facility discharge diagnosis subarachnoid hemorrhage posterior communicating artery aneurysm discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions surgery procedures you had a cerebral angiogram to coil the aneurysm you may experience some mild tenderness and bruising at the puncture site groin activity we recommend that you avoid heavy lifting running climbing or other strenuous exercise until your follow up appointment you make take leisurely walks and slowly increase your activity at your own pace try to do too much all at once you make take a shower no driving while taking any narcotic or sedating medication if you experienced a seizure while admitted you must refrain from driving medications resume your normal medications and begin new medications as directed you have been discharged on a medication called nimodipine this medication is used to help prevent cerebral vasospasm narrowing of blood vessels in the brain you have been discharged on keppra levetiracetam this medication helps to prevent seizures please continue this medication until follow up it is important that you take this medication consistently and on time you have been discharged on a medication to lower your cholesterol levels we recommend that you continue this medication indefinitely you may use acetaminophen tylenol for minor discomfort if you are not otherwise restricted from taking this medication what you experience mild to moderate headaches that last several days to a few weeks difficulty with short term memory fatigue is very normal constipation is common be sure to drink plenty of fluids and eat a high fiber diet if you are taking narcotics prescription pain medications try an over the counter stool softener when to call your doctor at for severe pain swelling redness or drainage from the incision site or puncture site fever greater than degrees fahrenheit constipation blood in your stool or urine nausea and or vomiting extreme sleepiness and not being able to stay awake severe headaches not relieved by pain relievers seizures any new problems with your vision or ability to speak weakness or changes in sensation in your face arms or leg call and go to the nearest emergency room if you experience any of the following sudden numbness or weakness in the face arm or leg sudden confusion or trouble speaking or understanding sudden trouble walking dizziness or loss of balance or coordination sudden severe headaches with no known reason followup instructions

name unit no admission date discharge date date of birth sex f service neurosurgery allergies no known allergies adverse drug reactions attending chief complaint cerebral aneurysm major surgical or invasive procedure pipeline embolization of left ica aneurysm history of present illness with recanalized p comm aneurysm she is s p sah w coiling left p comm she presents today for pipeline embolization of left ica aneurysm past medical history htn hyperlipidemia depression arthritis h pylori colon polyp bilateral osteoarthritis of the knees s p right total knee replacement colon polyp gastritis esophagus social history family history no family history of neurologic diease or aneurysms physical exam on discharge opens eyes x spontaneous to voice to noxious orientation x person x place x time follows commands x simple x complex none pupils right left eom x full restricted face symmetric x yes notongue midline x yes no pronator drift yes x no speech fluent x yes no comprehension intact x yes no motor trapdeltoidbiceptricepgrip ipquadhamatehlgast wound cdi right groin covered angio groin site x soft no hematoma x palpable pulses pertinent results please see omr for pertinent imaging lab results brief hospital course on ms was admitted for pipeline embolization of l ica aneurysm her operative course was uncomplicated please see omr note for full details ica ms was transferred from the pacu to the her foley catheter was removed and she was encouraged to get out of bed as tolerated she mobilized well and was discharge home medications on admission asa plavix hctz qd garlic fatty acids discharge medications acetaminophen mg po q6h prn fever or pain aspirin mg po daily rx aspirin mg one tablet s by mouth once a day disp tablet refills clopidogrel mg po daily rx clopidogrel mg one tablet s by mouth once a day disp tablet refills hydrochlorothiazide mg po daily discharge disposition home discharge diagnosis cerebral aneurysm discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions angioplasty and stent activity you may gradually return to your normal activities but we recommend you take it easy for the next hours to avoid bleeding from your groin heavy lifting running climbing or other strenuous exercise should be avoided for ten days this is to prevent bleeding from your groin you make take leisurely walks and slowly increase your activity at your own pace try to do too much all at once do not go swimming or submerge yourself in water for five days after your procedure you make take a shower medications resume your normal medications and begin new medications as directed it is very important to take the medication your doctor prescribe for you to keep your blood thin and slippery this will prevent clots from developing and sticking to the stent you may use acetaminophen tylenol for minor discomfort if you are not otherwise restricted from taking this medication if you take metformin glucophage you may start it again three days after your procedure care of the puncture site you will have a small bandage over the site remove the bandage in hours by soaking it with water and gently peeling it off keep the site clean with soap and water and dry it carefully you may use a band aid if you wish what you experience mild tenderness and bruising at the puncture site groin soreness in your arms from the intravenous lines the medication may make you bleed or bruise easily fatigue is very normal when to call your doctor at for severe pain swelling redness or drainage from the puncture site fever greater than degrees fahrenheit constipation blood in your stool or urine nausea and or vomiting call and go to the nearest emergency room if you experience any of the following sudden numbness or weakness in the face arm or leg sudden confusion or trouble speaking or understanding sudden trouble walking dizziness or loss of balance or coordination sudden severe headaches with no known reason followup instructions

name no admission date discharge date date of birth sex f service medicine allergies bactrim ciprofloxacin erythromycin base metronidazole penicillins lisinopril phenobarbital phenobarbital attending chief complaint septic shock major surgical or invasive procedure none history of present illness yof with history of copd not on home o2 afib on apixaban and recent hospitalization for copd flare discharged who presented to osh today with cough and fever now transferred to for concern of septic shock after her hospitalization for copd flare she had been fatigued but was at her baseline from a breathing standpoint she had a fever to yesterday and developed a cough she did not complain of neck stiffness chest pain abdominal pain diarrhea dysuria or flank pain her daughter called ems because of her fever and cough and she was found by ems to have o2 sat in the high before transport to ed in the ed initial vitals ra exam notable for crackles at lung bases l r abdomen s nt nd and cva tenderness absent labs were notable for wbc procalcitonin lactate bnp and ua with protein wbc and few bacteria imaging lll haziness patient was given 2l ns vancomycin and aztreonam blood and urine cultures obtained her blood pressure continued to downtrend despite 2l ns and was started on levophed because icu beds were fully occupied at she was transferred to the icu on arrival to the micu she was on levophed weaned to with stable bps she complains of a mild productive cough but does not complain of neck stiffness shortness of breath chest pain abdominal pain or flank pain she has not noticed any recent rashes review of systems per hpi otherwise point ros negative past medical history copd not on home o2 diabetes hyperlipidemia hypertension hypothyroidism knee surgery right breast lumpectomy cataracts social history family history non contributory physical exam admission physical exam vitals see metavision general alert oriented no acute distress heent sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs non labored breathing no wheezes crackles heard in bilateral lung bases l r 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 pulses no clubbing cyanosis or edema skin dry and intact neuro aox3 moving all extremities access peripheral ivs discharge physical exam vs ra pain zero out of gen nad sitting up in bed heent mmm anicteric cv irreg irreg intermittently otherwise rrr no murmur pulm no wheeze crackles at left base normal wob comfortable abd soft nt nd nabs ext no edema skin warm dry neuro aaox3 fluent speech psych calm appropriate pertinent results admission labs 12pm urine color straw appear clear sp 12pm urine blood neg nitrite neg protein tr glucose ketone tr bilirubin neg urobilngn neg ph leuk tr 12pm urine rbc wbc bacteria none yeast none epi 12pm urine mucous rare 31pm other body fluid fluapcr negative flubpcr negative 22pm glucose urea n creat sodium potassium chloride total co2 anion gap 22pm estgfr using this 22pm alt sgpt ast sgot ld ldh alk phos tot bili 22pm albumin calcium phosphate magnesium 22pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 22pm neuts lymphs monos eos basos im absneut abslymp absmono abseos absbaso 22pm plt count 22pm ptt cxr right lung is clear opacification of the base of the left lung could be pneumonia but there is some leftward mediastinal shift suggesting atelectasis as well and an accompanying small left pleural effusion the heart is top normal size no pulmonary edema microbiology 31pm other body fluid fluapcr negative flubpcr negative mrsa screen negative urine legionella ag negative urine strep ag negative urine culture negative blood culture x no growth final discharge labs 36am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 35am blood glucose urean creat na k cl hco3 angap 35am blood calcium phos mg yof with pmh of copd not on home o2 afib recent hospitalization for copd flare discharged who presented to osh today with cough and fever now transferred to for septic shock brbpr likely small lgib from hemorrhoids stable h h can f u as outpatient septic shock hcap vs cap fever and hypotension and positive cxr findings are consistent with septic shock from pneumonia presumed to be hcap vs cap due to recent hospitalization she has mildly elevated bnp which is common in patients with diabetes hld copd and concern for cardiogenic shock is low osh ucx could be c w uti but is being adequately covered with cefepime all blood cultures including and with no growth legionella and strep antigens were both negative she was transitioned to a po antibiotic regimen of antibiotics with plan for days of antibiotics with cefpodoxime and doxycycline day last day copd no acute flare she is breathing comfortably on room air and maintaining o2 sats there is no evidence for copd exacerbation she is not wheezy on exam continue hold off on steroids for now but low threshold to re start it should she become more sob she did not require supplemental o2 with activity consider outpatient pft s and referral to pulmonary atrial fibrillation rate control on diltiazem and ac with apixaban hypothyroidism continued home levothyroxine dose medications on admission the preadmission medication list is accurate and complete atorvastatin mg po qpm apixaban mg po bid diltiazem extended release mg po daily levothyroxine sodium mcg po daily mirtazapine mg po qhs ipratropium albuterol neb neb neb q6h prn dyspnea vitamin d unit po daily symbicort budesonide formoterol mcg actuation inhalation bid albuterol inhaler puff ih q4h prn dyspnea discharge medications albuterol inhaler puff ih q4h prn dyspnea apixaban mg po bid atorvastatin mg po qpm diltiazem extended release mg po daily vitamin d unit po daily mirtazapine mg po qhs levothyroxine sodium mcg po daily ipratropium albuterol neb neb neb q6h prn dyspnea symbicort budesonide formoterol mcg actuation inhalation bid cefpodoxime proxetil mg po q12h duration days last day rx cefpodoxime mg tablet s by mouth every hours disp tablet refills doxycycline hyclate mg po q12h duration days last day rx doxycycline hyclate mg capsule s by mouth every hours disp capsule refills benzonatate mg po tid prn cough rx benzonatate mg capsule s by mouth three times daily disp capsule refills guaifenesin codeine phosphate ml po q6h prn cough rx codeine guaifenesin mg mg ml ml by mouth every six hours refills ondansetron mg po q8h prn nausea rx ondansetron hcl mg tablet s by mouth every hours disp tablet refills discharge disposition home discharge diagnosis septic shock due to pneumonia discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you initially presented to you were found to have a severe infection causing low blood pressure hypotension shock likely from pneumonia requiring admission to the icu for which you were transferred to icu you required brief blood pressure supporting medication called pressor in the icu but you responded well to antibiotics you are now being discharged to home to complete a course of antibiotics you will need to follow up with your pcp we recommend you have a repeat cxr in weeks to assess for resolution of your pneumonia followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies bactrim attending chief complaint cough sob major surgical or invasive procedure broncoscopy history of present illness ms is a female with the past medical history of tobacco use thc vaping exercise induced asthma and dvt pe one in and another in post surgery immobilization who presents with worsening cough and sob x week initially started having the cough in and presented to pcp where she got abx and inhaled steroids and felt somewhat better she was in for most of until and was feeling improved during that time since her cough started to worsen sometimes productive with yellow green sputum now over the past week she has started to have significant sob that is preventing her from performing her daily activities it is mostly exertional even when she walks to bathroom she denies orthopnea pnd she says she has required frequent albuterol inhalers w o improvement she has hx of pe but says these symptoms are different and she has been compliant with her xarelto she takes tylenol daily for frequent aches and pains currently she is having a ha in the middle of her forehead tylenol has not helped she has a hx of frequent pseudophed use for sinus headaches but she hasn t used it for a month doesn t have rhinorrhea or congestion but does have some pain when pressing on her nose she denies any ill contacts she also endorses a history of daily vaping for several years in the ed she was afebrile hr in sbp 140s 200s rr and ranged from being on 4l o2 presumably for comfort and then on ra labs in ed were concerning for leukocytosis with wbc and increased eosinophils she was given frequent nebs iv steroids and a dose of rocephin azithromycin pt reports improvement following this treatment imaging in ed cxr no focal consolidation pleural effusion or evidence of pneumothorax is seen the cardiac and mediastinal silhouettes are stable cta chest no evidence of pulmonary embolism or aortic abnormality scattered bilateral ground glass opacities may be due to aspiration pneumonitis versus atypical pneumonia versus less likely pulmonary edema scattered areas of bronchiectasis and bronchial wall thickening suggestive of small airways disease mm solid nodule at the left lung base recommendation as below for incidentally detected single solid pulmonary nodule bigger than 8mm a follow up ct in months a pet ct or tissue sampling is recommended on review of systems patient denies fever chills vision changes hearing changes sore throat rhinorrhea congestion back pain extremity pain extremity swelling dysuria hematuria urinary urgency urinary frequency abdominal pain nausea vomiting diarrhea or constipation falls dizziness productive cough dyspnea on exertion headache night sweats x1 week ekg sinus tachycardia past medical history hx of pe dvt in in setting of post surgery asthma pcos c b menorrhagia depression anxiety fatty liver borderline personality disorder gastroparesis bacterial overgrowth and pelvic floor dyssynergy gerd ankle fracture s p surgery x2 with pins finger surgery c diff infection hospital acquired social history family history dad died of a brain aneurysm no history of vte in any family member physical exam physical exam on admission vitals afebrile and vital signs stable see eflowsheet on l nc for comfort general alert and in no apparent distress eyes anicteric pupils equally round ent ears and nose without visible erythema masses or trauma oropharynx without visible lesion erythema or exudate no sinus tenderness cv heart regular tachycardic no murmur no s3 no s4 resp bilateral wheezing present l r breathing is non labored gi abdomen soft non distended non tender to palpation bowel sounds present gu no suprapubic fullness or tenderness to palpation msk neck supple moves all extremities strength grossly full and symmetric bilaterally in all limbs skin no rashes or ulcerations noted neuro alert oriented face symmetric gaze conjugate with eomi speech fluent moves all limbs psych pleasant appropriate affect physical exam on discharge vitals bp hr r ra general alert and in no apparent distress obese eyes anicteric pupils equally round ent ears and nose without visible erythema masses or trauma oropharynx without visible lesion erythema or exudate cv rrr no murmur no s3 no s4 no resp clear b l on auscultation breathing is non labored speaking in full sentences gi deferred gu deferred msk neck supple moves all extremities strength grossly full and symmetric bilaterally in all limbs skin healed scars on lower legs neuro alert oriented face symmetric gaze conjugate with eomi speech fluent moves all limbs psych pleasant appropriate affect pertinent results labs on admission 24pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 24pm blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 24pm blood glucose urean creat na k cl hco3 angap pertinent interval labs 40am blood anca positive protienase 3ab positive mco negative 40am blood igg iga igm coccidioides antibodies to tp and f antigens id test result reference range units ab to tp antigen igm negative ab to f antigen igg negative aspergillus antibody test result reference range units aspergillus ab negative negative aspergillus fumigatus ab negative negative interpretive criteria negative antibody not detected positive antibody detected a positive result is represented by or more precipitin bands and may indicate fungus ball allergic bronchopulmonary aspergillosis aba or invasive aspergillosis generally the appearance of bands indicates either fungus ball or aba test result reference range units aspergillus flavus ab negative negative ige test result reference range units immunoglobulin e h or rast testing see report in omr labs on discharge 15am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 15am blood glucose urean creat na k cl hco3 angap 40am blood alt ast alkphos totbili 15am blood calcium phos mg microbiology blood cultures x2 negative rapid respiratory viral screen culture negatve bronchoalveolar lavage gram stain final per 1000x field polymorphonuclear leukocytes per 1000x field gram positive cocci in pairs and in short chains per 1000x field gram positive cocci in clusters this is a concentrated smear made by cytospin method please refer to hematology for a quantitative white blood cell count if applicable respiratory culture final cfu ml commensal respiratory flora staph aureus coag cfu ml staphylococcus species may develop resistance during prolonged therapy with quinolones therefore isolates that are initially susceptible may become resistant within three to four days after initiation of therapy testing of repeat isolates may be warranted oxacillin resistant staphylococci must be reported as also resistant to other penicillins cephalosporins carbacephems carbapenems and beta lactamase inhibitor combinations rifampin should not be used alone for therapy sensitivities mic expressed in mcg ml staph aureus coag clindamycin s erythromycin r gentamicin s levofloxacin s oxacillin r rifampin s tetracycline s trimethoprim sulfa s vancomycin s potassium hydroxide preparation final no fungal elements seen fungal culture preliminary no fungus isolated acid fast smear final no acid fast bacilli seen on concentrated smear acid fast culture preliminary rapid respiratory viral screen culture negative inadecuate imaging studies chest xray pa and lat impression no acute cardiopulmonary process cta chest impression no evidence of pulmonary embolism or aortic abnormality scattered bilateral ground glass opacities may be due to aspiration pneumonitis versus atypical pneumonia versus less likely pulmonary edema scattered areas of bronchiectasis and bronchial wall thickening suggestive of small airways disease mm solid nodule at the left lung base recommendation as below recommendation s for incidentally detected single solid pulmonary nodule bigger than 8mm a follow up ct in months a pet ct or tissue sampling is recommended bronchoscopy report findings secretions quantity moderate color white consistency thick patient had thickened secretions plugging numerous airways bilaterally lingula lll rul rml rll these were difficult to remove and formed an airway cast see images above a bronchoalveolar lavage with ml of saline was performed in the right middle lobe bronchus frothy return with some plugs was obtained total of 35cc was returned summary airways showed thick sticky mucus diffusely and bal was performed with good return impressions secretions airway obstruction plan follow up microbiology follow up cytology chest x ray ap impression no pneumothorax status post bronchoscopy mild pulmonary edema ct sinus impression moderate paranasal sinus opacification without air fluid levels hyperostosis or bone destruction to suggest upper respiratory manifestations of granulomatosis with polyangiitis brief hospital course ms is a female with the past medical history of tobacco use thc vaping exercise induced asthma and dvt pe one in and another in post surgery immobilization who presents with worsening cough and sob x week eosinophilic granulomatosis with polyangitis pneumonia asthma exacerbation the patient presented with worsening cough and shortness of breath ct scan on admission showed multifocal pneumonia the differential for the patient s presentation included egpa vs aep vs vaping related lung disease with less likely apba or coccidioides the patient was also noted to have a significant peripheral eosinophilia she was initially started on ceftraixone azithromycin for treatment of cap which was transitioned to vancomycin when sputum from bal was for mrsa she was ultimately transitioned to clindamycin to complete a day course of antibiotics following bronchoscopy the patient was started on prednisone 60mg daily she had a ct sinus which did not show evidence of egpa she was also evaluated by dermatology who found no skin lesions to biopsy ultimately the patient s anca pr3 antibodies returned positive in addition she was found to have a significantly elevated ige the combination of anca positivity eosinophilia lung findings are consistent with egpa the patient was discharged on prednisone 40mg daily to continue until close pulmonary follow up she was continued on a ppi and started on atovaquone for pjp ppx she was also started on advair ecg was without significant abnormalities the patient will need an echocardiogram as an outpatient to asses for cardiac involvement of egpa the patient had significant improvement in her symptoms prior to discharge hypertension the patient was noted to have significantly elevated blood pressures she was started on hctz which was uptitrated to 50mg daily and then amiodarone was added blood pressures not optimally controlled on discharge will likely require additional titration vulvovaginal candidiasis patient was given fluconazole x2 chronic stable problems dvt pe on xarelto at home no pe seen on cta continued home xarelto qd tobacco use the patient was counseled on smoking cessation she expressed interest in chantix and was provided a prescription on discharge mood disorder the patient was continued on her home medications while hospitalized she has follow up scheduled with her psychiatrist the week after discharge transitional issues please arrange outpatient echocardiogram continue to monitor blood pressure may require additional medications discharged on chantix for smoking cessation would continue to encourage smoking cessation patient has follow up scheduled with pulmonary can consider referral to rheumatology as outpatient code full patient seen and examined on day of discharge minutes on discharge activities medications on admission the preadmission medication list is accurate and complete rivaroxaban mg po daily clonidine mg po daily mirtazapine mg po hs proair hfa albuterol sulfate mcg actuation inhalation q4 6h prn sob wheezing lorazepam mg po daily prn anxiety lamictal xr lamotrigine mg oral qhs omeprazole mg po daily gabapentin mg po tid docusate sodium mg po bid prn constipation first line bupropion xl once daily mg po daily triamcinolone acetonide cream appl tp bid prn rash mirena levonorgestrel mcg hours yrs mg injection fluticasone propionate 110mcg puff ih bid buspirone mg po bid discharge medications acetaminophen mg po q6h prn pain mild fever albuterol inhaler puff ih q4h prn sob amlodipine mg po daily rx amlodipine mg tablet s by mouth once a day disp tablet refills atovaquone suspension mg po daily rx atovaquone mepron mg ml ml by mouth once a day refills calcium d calcium carbonate vitamin d3 mg 250mg unit oral daily chantix varenicline mg oral daily days bid days bid for weeks rx varenicline chantix starting month box mg mg tablet s by mouth as dir disp dose pack refills clindamycin mg po ng q6h rx clindamycin hcl cleocin hcl mg capsule s by mouth q6hrs disp capsule refills fluticasone propionate nasal spry nu bid rx fluticasone propionate mcg actuation spray nas twice a day disp spray refills fluticasone salmeterol diskus inh ih bid rx fluticasone propion salmeterol advair diskus mcg mcg dose puff inh twice a day disp disk refills hydrochlorothiazide mg po daily rx hydrochlorothiazide mg mg by mouth once a day disp tablet refills prednisone mg po daily rx prednisone mg tablet s by mouth once a day disp tablet refills gabapentin mg po qid bupropion xl once daily mg po daily buspirone mg po bid clonidine mg po daily docusate sodium mg po bid prn constipation first line lamictal xr lamotrigine mg oral qhs lorazepam mg po daily prn anxiety mirena levonorgestrel mcg hours yrs mg injection mirtazapine mg po hs omeprazole mg po daily proair hfa albuterol sulfate mcg actuation inhalation q4 6h prn sob wheezing rivaroxaban mg po daily triamcinolone acetonide cream appl tp bid prn rash discharge disposition home discharge diagnosis eosinophilic granulomatosis with polyangitis hypertension pneumonia 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 during your admission to you were evaluated for shortness of breath you were seen by the pulmonary team and had a cat scan and a bronchoscopy in addition to a number of lab tests you were treated for pneumonia with antibiotics while you were hospitalized the results of your studies indicate you likely have eosinophilic granulomatosis with polyangitis egpa you were started on steroids which will treat this condition you have also been given new inhalers to help your breathing it is important that you stop smoking and vaping you were started on chantix to help with this while you take steroids you should take a medication to protect your stomach and calcium with vitamin d to protect your bones you have also been started on an antibiotic to prevent an infection while you are on steroids you were found to have high blood pressure during your hospitalization you have been started on new blood pressure medications it is important that you follow up with your pcp and with the pulmonary team on discharge your primary care doctor refer you for an echocardiogram we wish you the best your care team followup instructions

name unit no admission date discharge date date of birth sex m service surgery allergies lisinopril attending chief complaint morbid obesity major surgical or invasive procedure laparoscopic sleeve gastrectomy history of present illness has class iii morbid obesity with weight of pounds as of with his initial screen weight of pounds on height inches and bmi of his previous weight loss efforts have included weight watchers the diet taking off pounds sensibly tops rd dietitian visits self directed diabetic diet for months losing pounds in a month group weight loss program losing pounds he has not taken prescription weight loss medications and he has tried over the counter ephedra containing appetite suppressants he stated that his lowest adult weight was pounds in at the age of and his highest weight is his weight of pounds on he stated that he has been struggling with weight since his teenage years and factors contributing to his excess weight include large portions late night eating grazing too many carbohydrates and saturated fats and convenience eating in high school he played football and he had been active for quite some time he did enjoy water aerobics and in he was in cardiac rehabilitation and did walking stretching and lifting weights however he is currently not exercising secondary to physical limitations especially joint pain he denied history of eating disorders denied binge eating he does not have a clinical diagnosis of depression except for situational around his weight he is currently not seeing a therapist nor has he been hospitalized for mental health issues and he is not on any psychotropic medications past medical history hypertension type diabetes with hemoglobin a1c of obstructive sleep apnea on cpap hyperlipidemia with elevated triglycerides chronic kidney disease stage iii with creatinine gout osteoarthritis with joint pain umbilical hernia hepatic steatosis erectile dysfunction vitamin d deficiency history of umbilical hernia leukocytosis heartburn reflux mild history of anemia history of edema with lower extremity venous stasis hyperparathyroidism colonic polyps adenoma by colonoscopy his surgical history is noted for aortic valve and aortic root replacement at left knee replacement in right carpal tunnel release left carpal tunnel release in social history family history he denied tobacco or recreational drug usage has alcohol on occasion drinks ounces cup of coffee up to times a day and has a ounce can of diet soda daily he is married living with his wife and they have children one daughter deceased at the age of from neuroblastoma another daughter with history of thyroid ca sons one with lymphoma he is retired from work at and currently works for during the tax season physical exam temp po bp hr rr o2 sat o2 delivery ra fsbg total intake 2667ml po amt 690ml iv amt infused 1977ml total intake 2776ml po amt 1050ml iv amt infused 1726ml total output 0ml urine amt 0ml total output 1350ml urine amt 1350ml physical exam general well appearing no acute distress cv rrr pulm breathing comfortably on ra abdomen appropriate tenderness to palpation mildly distended incision c d i extremities warm well perfused pulses intact pertinent results 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 29am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood glucose urean creat na k cl hco3 angap 29am blood glucose urean creat na k cl hco3 angap 00am blood alt ast alkphos totbili 00am blood calcium phos mg 29am blood calcium phos mg brief hospital course mr is a with morbid obesity who underwent a laparoscopic sleeve gastrectomy on there were no adverse events in the operating room please see the operative note for details pt was extubated taken to the pacu until stable then transferred to the ward for observation neuro the patient was alert and oriented throughout hospitalization pain was managed with a preoperative tap block and postoperative ketorolac gabapentin and acetaminophen opioid medication was used only for severe breakthrough pain prn 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 afterwards the patient was started on a stage bariatric diet which the patient tolerated well subsequently the patient was advanced to stage which the patient was tolerating on day of discharge id the patient s fever curves were closely watched for signs of infection 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 on post operative day the patient was started on lovenox with a plan to bridge his lovenox to warfarin for his prostetic heart valve after discharge from the hospital the patient will follow up with his out patient warfarin provider to begin the bridge from lovenox to warfarin endocrine the patient had difficult to control glucose via finger stick blood glucose post operatively the diabetes service was consulted for assistance with management of the patient s blood glucose at the time of discharge the patient had better glycemic control however he will require close follow up with his primary endocrinologist to continue to manage his insulin regimen as an outpatient he was discharged with a new prescription for humalog and instructions to closely follow up with his primary endocrinologist at the time of discharge the patient was doing well afebrile and hemodynamically stable the patient was tolerating a bariatric stage 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 losartan potassium mg po daily allopurinol mg po daily atenolol mg po daily metformin glucophage mg po daily metformin glucophage mg po daily warfarin mg po asdir atorvastatin mg po qpm units q12h glargine units breakfast torsemide mg po daily omeprazole mg po daily aspirin mg po daily vitamin d unit po daily discharge medications acetaminophen liquid mg po q8h prn pain mild fever rx acetaminophen mg ml ml by mouth q8hr prn disp milliliter refills enoxaparin sodium mg sc bid rx enoxaparin mg ml mg sc twice a day disp syringe refills glargine units lunch insulin sc sliding scale using hum insulin rx insulin lispro humalog u insulin unit ml as dir units sc up to units qid per sliding scale disp vial refills glargine units breakfast allopurinol mg po daily aspirin mg po daily atenolol mg po daily atorvastatin mg po qpm losartan potassium mg po daily omeprazole mg po daily open capsule sprinkle contents onto applesauce swallow whole torsemide mg po daily vitamin d unit po daily warfarin mg po asdir held metformin glucophage mg po daily this medication was held do not restart metformin glucophage until you speak with your endocrinologist held metformin glucophage mg po daily this medication was held do not restart metformin glucophage until you speak with your endocrinologist discharge disposition home discharge diagnosis morbid obesity diabetes mellitus chronic kidney disease stage iii discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr you have undergone a laparoscopic sleeve gastrectomy recovered in the hospital are now preparing for discharge with 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 ii diet until your follow up appointment this stage was previously called stage iii and consists of protein shakes sugar free smooth pudding yogurt etc please refer to your work book for detailed instructions do not self advance your diet and avoid drinking with a straw or chewing gum to avoid dehydration remember to sip small amounts of fluid frequently throughout the day to reach a goal of approximately ml per day please note the following signs of dehydration dry mouth rapid heartbeat feeling dizzy or faint dark colored urine infrequent urination 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 pain medication you will receive a prescription for liquid acetaminophen tylenol do not exceed mg per hour period antacids you will be taking famotidine tablets mg twice daily for one month this medicine reduces stomach acid production please crush you must not use nsaids non steroidal anti inflammatory drugs unless approved by your weight loss surgery team 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 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 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 strips seven to days after surgery you may shower 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 months do not use any ointments on the incision unless you were told otherwise followup instructions

name unit no admission date discharge date date of birth sex m service surgery allergies lisinopril attending chief complaint hepatic biopsy bleed major surgical or invasive procedure none history of present illness mr is a male with morbid type iii status post laparoscopic sleeve gastrectomy and liver biopsy x2 on who presents to the hospital as a transfer for low hematocrit in brief he is a male patient with morbid obesity type iii who underwent that laparoscopic sleeve gastrectomy on he was discharged on on lovenox and coumadin given his history of aortic valve replacement on he went to an outside hospital for an inr check and was found to have hemoglobin of and a hematocrit of his last hemoglobin hematocrit at the hospital on was and respectively given this drop in his labs he was transferred to the emergency department at since his discharge he reports having no pain and has not bowel movement since days but continues to pass gas he denies chills fevers chest pain palpitations shortness of breath hematemesis melena dizziness syncope and headache rest of ros are negative past medical history hypertension type diabetes with hemoglobin a1c of obstructive sleep apnea on cpap hyperlipidemia with elevated triglycerides chronic kidney disease stage iii with creatinine gout osteoarthritis with joint pain umbilical hernia hepatic steatosis erectile dysfunction vitamin d deficiency history of umbilical hernia leukocytosis heartburn reflux mild history of anemia history of edema with lower extremity venous stasis hyperparathyroidism colonic polyps adenoma by colonoscopy his surgical history is noted for aortic valve and aortic root replacement at left knee replacement in right carpal tunnel release left carpal tunnel release in social history family history he denied tobacco or recreational drug usage has alcohol on occasion drinks ounces cup of coffee up to times a day and has a ounce can of diet soda daily he is married living with his wife and they have children one daughter deceased at the age of from neuroblastoma another daughter with history of thyroid ca sons one with lymphoma he is retired from work at and currently works for during the tax season physical exam temp po bp l lying hr rr o2 sat o2 delivery ra fsbg total intake 253ml po amt 120ml iv amt infused 133ml total intake 888ml po amt 480ml iv amt infused 408ml total output 0ml urine amt 0ml physical exam general well appearing no acute distress cv rrr pulm breathing comfortably on ra abdomen appropriate tenderness to palpation mildly distended incision c d i extremities warm well perfused pulses intact pertinent results 28am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 04am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 24am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 28am blood ptt 59pm blood ptt 52pm blood ptt 28am blood glucose urean creat na k cl hco3 angap 04am blood glucose urean creat na k cl hco3 angap 24am blood glucose urean creat na k cl hco3 angap 28am blood alt ast alkphos totbili 04am blood alt ast alkphos totbili 24am blood alt ast alkphos totbili 28am blood calcium phos mg 04am blood calcium phos mg 24am blood calcium phos mg with morbid obesity s p laparoscopic sleeve gastrectomy liver bx x2 presents to ed for low hct in setting of post operative bleed the patient was admitted to the surgical icu for close hemodynamic monitoring and blood transfusions he was started on a heparin drip for anticoagulation for his synthetic aortic valve his hematocrit continued to drift down requiring multiple transfusions of packed red blood cells on the patient received a ct scan of the abdomen and pelvis which showed a intra abdominal hematoma which was in the liver a cta was performed in interventional radiology was consulted however no active bleed was identified and they were unable to embolize the bleeding vessel on the patient was called out of the icu to the floor his hematocrit was monitored every hours he was continued on heparin drip and bridged to his home dose of warfarin with a goal inr due to the patient s elevated total bilirubin of the transplant surgery team was consulted there is no indication for surgical intervention and the patient s bilirubin continued to be trended throughout his hospitalization on the patient s inr had reached therapeutic range he was continued on his home warfarin dose of mg his heparin drip was discontinued his hematocrit had remained stable and he was deemed appropriate for discharge home on the day of discharge the patient was tolerating regular diet he had no abdominal pain his hematocrit had remained stable and he was therapeutic on his home warfarin dose his fingerstick blood glucose was well controlled on his insulin regimen which was managed by the diabetes service he was discharged home to continue his coumadin and monitoring with his clinic he will also have close follow up with dr in the bariatric surgery clinic medications on admission the preadmission medication list is accurate and complete aspirin mg po daily atenolol mg po daily losartan potassium mg po daily atorvastatin mg po qpm omeprazole mg po daily torsemide mg po daily allopurinol mg po daily warfarin mg po daily16 acetaminophen liquid mg po q6h prn pain mild fever enoxaparin sodium mg sc bid glargine units breakfast humalog units lunch humalog units dinner discharge medications glargine units breakfast humalog units lunch humalog units dinner acetaminophen liquid mg po q6h prn pain mild fever allopurinol mg po daily aspirin mg po daily atenolol mg po daily atorvastatin mg po qpm losartan potassium mg po daily omeprazole mg po daily torsemide mg po daily warfarin mg po daily16 discharge disposition home discharge diagnosis liver biopsy bleed discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr you were admitted to the hospital for a bleed from your liver biopsy site which has now resolved you have recovered in the hospital are now preparing for discharge with 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 ii diet until your follow up appointment this stage was previously called stage iii and consists of protein shakes sugar free smooth pudding yogurt etc please refer to your work book for detailed instructions do not self advance your diet and avoid drinking with a straw or chewing gum to avoid dehydration remember to sip small amounts of fluid frequently throughout the day to reach a goal of approximately ml per day please note the following signs of dehydration dry mouth rapid heartbeat feeling dizzy or faint dark colored urine infrequent urination 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 pain medication you will receive a prescription for liquid acetaminophen tylenol do not exceed mg per hour period antacids you will be taking famotidine tablets mg twice daily for one month this medicine reduces stomach acid production please crush you must not use nsaids non steroidal anti inflammatory drugs unless approved by your weight loss surgery team 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 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 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 strips seven to days after surgery you may shower 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 months do not use any ointments on the incision unless you were told otherwise followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies vicodin attending chief complaint dyspnea major surgical or invasive procedure interventional pulmonology tumor debulking and bilateral stent placement in the main stem bronchi ct chest angiogram used to assess for any pe or post surgical complications preliminary read showed no pulmonary emboli were identified at the lobar level though more distal emboli were not excluded history of present illness ms is a year old prior nurse depression anxiety fibromyalgia and sciatica who presented with dyspnea diagnosed with nsclc compressing her mainstem bronchi at transferred to for bronchoscopy with placement of bronchial stents patient was treated for a pneumonia this past but otherwise reports feeling well until weeks prior to admission she first noted a cough then food began feeling lodged in her throat and she became unable to keep food down leading to weight loss of about lbs over the past month two weeks prior to admission the patient felt she as though she were gasping for air when she coughed and she presented to where imaging and biopsy showed nsclc compressing her main bronchi bilaterally she also experienced low grade fevers at she was started on nebulizers and predisone 40mg po qd starting for hypoxia was treated with a course of ceftriaxone x 10d for post obstructive pna and was treated for pain with oxycodone 30mg po q6h per palliative care team in the setting of her fibromyalgia sciatica and psychiatric history pt endorses chest pain that radiates to the left side of her chest continued difficulty breathing and vaginal itching she denies fevers chills n v abd pain changes in bowel or bladder movement dysuria myalgias and arthralgias past medical history depression anxiety fibromyalgia sciatica s p tubal ligation s p venous stripping social history family history mother dm dementia schizophrenia nos bipolar father deceased from subdural hematoma brother schizophrenia nos bipolar physical exam admission physical exam vitals on fm general alert oriented labored rhoncorous breathing on fm heent sclera anicteric oropharynx clear with opaque mucous neck supple jvp not elevated no lad lungs inspiratory and expiratory wheezing rhonchi and rales bilaterally anteriorly and posteriorly cv rrr no r g m abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly gu no foley ext warm well perfused pulses no edema neuro cns2 intact pupils equal round and reactive to light motor function grossly normal discharge physical exam vitals 95ra general alert oriented laying in bed breathing comfortably on room air heent sclera anicteric mmm oropharynx clear lungs lungs rhoncorous bilaterally with mild wheezing 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 neuro cns2 intact motor function grossly normal pertinent results admission labs 58am glucose urea n creat sodium potassium chloride total co2 anion gap 58am wbc rbc hgb hct mcv mch mchc rdw rdwsd 58am plt count 58am ptt 58am albumin calcium phosphate magnesium 58am alt sgpt ast sgot alk phos tot bili cta chest impression suboptimal opacification of the pulmonary arteries within this limitation no obvious pulmonary embolism large mediastinal mass slightly larger than on the prior study patent left mainstem and right bronchus intermedius stents fluid filled esophagus at the level of carina which may predispose to aspiration discharge labs 46am blood glucose urean creat na k cl hco3 angap 46am blood calcium phos mg w depression anxiety fibromyalgia and sciatica who presented with dyspnea diagnosed with nsclc compressing her main stem bronchi at transferred for placement of bronchial stenting nsclc the patient was diagnosed with nsclc consistent with adenocarcinoma with extrinsic compression of both main stem bronchi transferred for endobronchial stenting by interventional pulmonology the oncology team at has had work up with negative head ct and cta a p for metastatic disease with plans for potential chemo xrt after stenting on admission the patient required 6l nc via venturi mask on the patient underwent tumor debulking and placement of bronchial stents bilaterally the patient was saturating well on room air following the procedure and started a day course of unasyn inpatient transitioned to augmentin outpatient 875mg po bid first day depression anxiety patient continued on her home alprazolam mg po ng qam alprazolam mg po ng qhs buspirone mg po bid escitalopram oxalate mg po ng daily fibromyalgia the patient s pain management was optimized with her outpatient and palliative care teams for pain control the patient continued on morphine sr ms mg po q8h morphine sulfate oral solution mg ml mg po q3h prn pain anxiety dyspnea and gabapentin mg po ng tid at osh vaginal pruritis patient likely had vaginal candidiasis and was treated with miconazole nitrate vag cream appl vg qd prn tobacco abuse patient continued on a nicotine patch mg daily transitional issues needs to be connected to oncology at needs follow up with interventional pulmonology in weeks with a ct chest scan needs continued pain management by primary care and oncology teams medications on admission the preadmission medication list is accurate and complete escitalopram oxalate mg po daily alprazolam mg po qam alprazolam mg po qhs buspirone mg po bid diazepam mg po daily prn anxiety oxycodone immediate release mg po q6h prn pain discharge medications alprazolam mg po qam alprazolam mg po qhs buspirone mg po bid escitalopram oxalate mg po daily diazepam mg po daily prn anxiety albuterol neb soln neb ih q2h prn dyspnea rx albuterol sulfate mg ml neb inhaled q4 hr disp vial refills gabapentin mg po tid rx gabapentin mg capsule s by mouth three times a day disp capsule refills guaifenesin er mg po q12h rx guaifenesin mg by mouth twice a day disp tablet refills lidocaine patch ptch td qpm rx lidocaine lidoderm lidoderm patch q q disp patch refills miconazole nitrate vag cream appl vg qd prn vaginal days rx miconazole nitrate miconazole vaginal cream application once a day disp tube refills morphine sulfate oral solution mg ml mg po q3h prn pain anxiety dyspnea rx morphine mg ml mg by mouth q3hr refills nicotine patch mg td daily rx nicotine mg hour mg td q disp patch refills ipratropium albuterol neb neb neb q6h rx ipratropium albuterol mg mg mg base ml nebulizer inhaled q hr disp ampule refills amoxicillin clavulanic acid mg po q12h duration days last day of antibiotics on rx amoxicillin pot clavulanate mg mg tablet by mouth q12hr disp tablet refills morphine sr ms mg po q8h rx morphine ms mg tablet s by mouth q8hr disp tablet refills equipment nebulizer machine icd c34 non small cell carcinoma of the lung duration of use months to be used with nebulizers as prescribed discharge disposition home discharge diagnosis primary non small cell lung cancer post obstructive pneumonia secondary vaginal candidiasis fibromyalgia depression anxiety sciatica 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 transferred with a tumor compressing your bronchi smaller airways leading to difficulty breathing the interventional pulmonology team took you to the operating room on to remove some of your tumor and place stents in your airways after the surgery your breathing improved you also have experienced episodes of chest pain that was reproducible with pressing on your chest some of the chest pain can occur following your surgery an electrocardiogram looking at your heart and lab tests sent were normal we are reassured that there are no acute issues with your heart that need immediate interventions finally you were experiencing episodes of tachycardia with fast heart beats the ekgs we captured of your heart were normal and the episodes of tachycardia seems to have decreased following management of your post surgical pain we recommend following up with your primary care physician about further work up please continue using the acapella flutter valve twice a day to help loosen the secretions in your air ways which will help prevent pneumonia please seek immediate care if you experience fevers chills chest pain difficulty breathing coughing up blood or any other concerning symptoms we wish you the best in your health your care team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies vicodin attending chief complaint dsypnea major surgical or invasive procedure bronchial and esophageal stent placement history of present illness y o female with history of recent diagnosis of adenocarcinoma of the lung now s p bronchial stenting depression anxiety fibromyalgia and sciatica in she was diagnosed with at with tumor compressing her main stem bronchi and thus she was admitted here at thru for tumor debulking and bronchial stenting upon discharge she was feeling well and breathing well on room air she then presented to on with increased work of breathing which was somewhat acute in onset on admission there she was initially trialled on nippv though did not tolerate this and she was placed on 6l nasal cannula she was able to do okay on nasal cannula she had a cta which was negative for pe but did show mass effect on the pulmonary arteries and central airway there was also nodular opacities at the lung bases bilaterally she was put on moxifloxacin and vancomycin for coverage for pneumonia respiratory panel legionella antigen and pneumococcal antigen were negative she was transferred to for ip evaluation and potential intervention per their discharge paperwork the patient has been set up for radiation oncology palliative radiation at though this has not occurred yet upon arrival here she notes stable dyspnea but feels okay at rest she is able to lie flat without any issues she cough but notes that she frequently chokes on food drink she also has dysphagia she notes low grade temperatures at home highest she denies abdominal pain nausea vomiting diarrhea she has pain across her chest which is constant and has been present for several weeks the pain is not made worse by movement or inspiration it is somewhat worse with swallowing ros no night sweats no changes in vision or hearing no changes in balance no cough no palpitations no nausea or vomiting no diarrhea or constipation no dysuria or hematuria no hematochezia no melena no numbness or weakness no focal deficits past medical history adenocarcinoma of the lung diagnosed depression anxiety fibromyalgia sciatica s p tubal ligation s p venous stripping social history family history mother dm dementia schizophrenia nos bipolar father deceased from subdural hematoma brother schizophrenia nos bipolar physical exam physical exam on admission vitals on 5l nc general alert oriented no acute distress heent sclerae anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs diffuse inspiratory and expiratory wheeze throughout cv rrr no murmur abdomen soft nt nd bowel sounds present no rebound tenderness or guarding no organomegaly gu no foley ext warm well perfused pulses no clubbing cyanosis or edema neuro cn2 intact no focal deficits physical exam on discharge afeb vss on room air general alert oriented no acute distress heent sclera anicteric neck supple jvp not elevated no lad lungs diffuse inspiratory and expiratory wheeze throughout cv rrr no murmur abdomen soft nt nd bowel sounds present ext no e c c pertinent results admission labs 45pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 45pm blood neuts bands lymphs monos eos baso metas myelos absneut abslymp absmono abseos absbaso 45pm blood hypochr normal anisocy normal poiklo normal macrocy normal microcy normal polychr normal 45pm blood ptt 45pm blood glucose urean creat na k cl hco3 angap 45pm blood alt ast ld ldh alkphos totbili 45pm blood probnp 45pm blood albumin calcium phos mg discharge labs imaging ct chest wtihout contrast impression overall similar appearance of the large posterior mediastinal mass resulting in esophageal obstruction as well as invasion of the carina and bilateral mainstem bronchi there is approximately narrowing of bilateral main stem bronchi proximal to the endobronchial stents interval increase in the left lower lobe bronchial obstruction with associated worsening left lower lobe consolidation and atelectasis chest portable ap impression in comparison with the scout radiograph of the ct examination dated there is again bilateral hilar prominence consistent with invasion of the carina and mainstem bronchi from a large posterior mediastinal mass the bronchial stents are not definitely appreciated on the current study increased opacification at the lung left base was shown to represent a combination of lower lobe atelectasis and consolidation chest portable ap impression comparison to the right paramediastinal mass appears slightly larger than on the previous examination moreover there is a new opacity projecting over the aortopulmonary window lung volumes have decreased the newly placed endobronchial stent is not directly visualized chest portable ap impression as compared to the previous image from the paramediastinal and perihilar opacities have improved and the lung has increased in transparent see also improved is a retrocardiac atelectasis the tracheal stent is not directly visualized borderline size of the heart no pneumothorax chest portable comparison to status post esophageal stent placement the paramediastinal opacity on the right is stable mild elevation of the left hemidiaphragm is unchanged there currently is no evidence for the presence of pneumonia or pneumothorax a small retrocardiac atelectasis is stable in extent and severity new ground glass opacity of the right upper lobe and increased peribronchiolar nodularity at the right lung base compatible with sequela of aspiration and or hemorrhage after bronchoscopy improvement of left lower lobe consolidation unchanged posterior mediastinal mass now with patent airways after tracheal stenting microbiology blood culture pending blood culture pending bronchial washings time taken not noted log in date time pm bronchial washings left bronchial wash gram stain final per 1000x field polymorphonuclear leukocytes per 1000x field gram positive cocci in clusters respiratory culture preliminary organisms ml commensal respiratory flora staph aureus coag organisms ml acid fast smear final no acid fast bacilli seen on concentrated smear acid fast culture preliminary fungal culture preliminary no fungus isolated surgical pathology left mainstem endobronchial lesion focal poorly differentiated carcinoma bronchial mucosa with squamous metaplasia acute and chronic inflammation and fibrinous exudate 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood glucose urean creat na k cl hco3 angap 00am blood calcium phos mg brief hospital course primary reason for hospitalization y o female with history of recent diagnosis of adenocarcinoma of the lung now s p bronchial stenting at depression anxiety fibromyalgia and sciatica she was initially seen at where she has been seeing dr and dr with plan for initiation of palliative chemo and radiation she was admitted for acute hypoxemic respiratory failure and was found to have increased bronchus narrowing due to increased size of mass she was transferred to for stenting she underwent tracheal and esophageal stent placements she requests transfer back to for urgent initiation of chemotherapy and radiation therapy active issues hypoxemia secondary to lung adenocarcinoma and post obstructive pneumonia s p tracheal y stenting with improvement in symptoms however developed recurrent sob requiring another bronchoscopy on showing occlusion requiring re stenting following this she had stabilization of dyspnea and hypoxia on room air at discharge continued on vanc mtz for concern of post obstructive pna mrsa isolated from bronchial washings continue a day course non small cell lung cancer recent diagnosis with mapping and plan for palliative chemo and radiation at she was evaluated by heme onc and onc at who recommended initiation of therapy as soon as possible given rapid growth and obstructive complications therapy was offered here at but patient prefers transfer back to so that her sister hcp can have ease of travel she is followed by dr radiation oncologist and dr oncology at she was maintained on a diluadid pca for pain control dysphagia she has dysphagia secondary to esophageal compression by mass she was seen by the ercp team at and underwent esophageal stent placement on with improvement in symptoms she was started on bid ppi due to pain related to the stent she should continue on a dysphagia soft diet due to her stent tachycardia patient was noted to have episodes of tachycardia with bigeminy trigeminy vs afib that was asymptomatic blood pressures stable during periods of tachycardia likely secondary to mediastinal mass burden started on low dose metoprolol which will likely need to be titrated up oral candidiasis patient was started on nystatin day chronic issues depression anxiety fibromyalgia she was continued on her home alprazolam buspirone and escitalopram transitional issues initiation of palliative xrt and chemotherapy continue vanc mtz through uptitration of metoprolol as needed for tachycardia transition to oral pain regimen medications on admission the preadmission medication list is accurate and complete acetylcysteine ml neb q6h albuterol neb soln neb ih q8h alprazolam mg po bid alprazolam mg po qhs buspirone mg po bid enoxaparin sodium mg sc daily escitalopram oxalate mg po daily gabapentin mg po q8h methylprednisolone sodium succ mg iv q8h morphine sr ms mg po q8h moxifloxacin mg other daily nicotine patch mg td daily unit po q8h nystatin unit gram topical bid vancomycin mg iv q 12h guaifenesin ac codeine guaifenesin mg ml oral q6h prn cough morphine sulfate oral solution mg ml mg po q3h prn pain morphine sulfate mg iv q2h prn pain lorazepam mg iv q6h prn anxiety discharge medications acetylcysteine ml neb q6h albuterol neb soln neb ih q8h alprazolam mg po bid alprazolam mg po qhs buspirone mg po bid escitalopram oxalate mg po daily gabapentin mg po q8h morphine sr ms mg po q8h morphine sulfate oral solution mg ml mg po q3h prn pain nicotine patch mg td daily unit po q8h guaifenesin ac codeine guaifenesin mg ml oral q6h prn cough vancomycin mg iv q 12h bisacodyl mg po pr daily prn constipation docusate sodium mg po bid levofloxacin mg iv q24h duration days metronidazole flagyl mg iv q8h metoprolol tartrate mg po qid hydromorphone dilaudid mg ivpca lockout interval minutes basal rate mg s hour hr max limit mg s start today lorazepam mg po q4h prn anxiety sodium chloride inhalation soln ml neb tid prn rhonchi shortness of breath ipratropium bromide neb neb ih q4h hydromorphone dilaudid mg iv q2h prn severe pain pantoprazole mg po q12h discharge disposition extended care discharge diagnosis lung adenocarcinoma discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear ms it was a pleasure taking care of you at you were transferred here for difficulty breathing you had procedures performed to place stents in you esophagus and your airways you had good improvement in your symptoms you were seen by our medical and radiation oncologists who recommended that you transfer back to hospital to pursue radiation therapy and chemotherapy as planned followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies codeine attending chief complaint dyspnea major surgical or invasive procedure bronchoscopy history of present illness mr is a man with a history of cad s p mi s stents on dual antiplatelet therapy aspirin brilinta t2dm asthma and left rotator cuff repair on complicated by pneumonia requiring icu stay intubation who was discharged days ago now presenting as a transfer from with malaise fatigue worsening of baseline chronic dry cough of note patient also endorses brbpr times approximately weeks he never felt back to baseline after being discharged from he has gotten progressively more fatigued over the past week with worsening dyspnea on exertion and cough he has had poor po intake during this time no fevers but occasional chills his physical therapist evaluated him today recommended he come to the ed for evaluation at chest x ray showed probable pneumonia patient was sent having already been given zosyn levoquin vancomycin l normal saline negative tropes blood cultures patient received a dre at positive guaiac and positive internal hemorrhoid the ed initial vs were ra exam notable for rales bilateral bases no dtp no accessory mm use rectal exam with guaiac pos stool and presence of internal hemorrhoid labs showed lactate wbc pmn s without bands imaging showed cxr pa lat extensive multi lobar interstitial opacities with background ground glass opacities bilaterally with volume loss suggestive of infectious or inflammatory etiology correlate with outside hospital course prior disease and consider sputum culture patient received zosyn levoquin vancomycin l normal saline all at transfer vs were 3l nc on arrival to the floor patient reports fatigue he continues to have a dry cough he has no dyspnea at rest or with talking but dyspnea with minor exertion past medical history recent left rotator cuff surgery c b pna requiring intubation htn hld obesity cad s p mi and pci with bare metal stent left anterior descending artery gerd asthma tobacco use congenital single kidney diverticulitis and partial colectomy memory loss anxiety psoriasis not on steroids currently social history family history father deceased with mets mi mother deceased multiple myeloma chf copd and dm sister cancer unknown type murdered od sis od meds and etoh children daughter healthy physical exam admission physical general lying bed nontoxic nad heent at nc eomi anicteric sclera pink conjunctiva mmm neck supple no lad no jvd heart rrr s1 s2 no murmurs gallops or rubs lungs normal work of breathing on 4l o2 without use of accessory muscles no crackles or wheezes appreciated good air movement abdomen nondistended nontender all quadrants no rebound guarding extremities no cyanosis clubbing or edema pulses dp pulses bilaterally neuro a ox3 moving all extremities with purpose skin warm and well perfused no excoriations or lesions no rashes discharge physical physical exam vitals bp127 hr71 rr21 2l general aox3 well appearing no acute distress heent sclera anicteric dry mucous membranes lungs scattered inspiratory crackles cv regular rate and rhythm normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present ext warm well perfused no edema left arm sling neuro grossly normal pertinent results admission labs 30pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 05am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30pm blood glucose urean creat na k cl hco3 angap 05am blood glucose urean creat na k cl hco3 angap 00pm blood ck cpk 05am blood calcium phos mg 40am blood calcium phos mg pertinent labs and imaging scleroderma antibody negative anti rnp negative pneumonitis hypersensitivity profile negative anti ccp negative anit jo1 negative aldolase negative micro am bronchoalveolar lavage right middle lobe gram stain final per 1000x field polymorphonuclear leukocytes per 1000x field gram positive cocci pairs and clusters respiratory culture final cfu ml commensal respiratory flora legionella culture preliminary no legionella isolated immunofluorescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii less than ml received interpret negative culture results with caution fungal culture preliminary nocardia culture preliminary acid fast smear preliminary acid fast culture preliminary am mrsa screen source nasal swab final report mrsa screen final no mrsa isolated am stool consistency not applicable source stool final report c difficile dna amplification assay final reported to and read back by 340pm clostridium difficile positive for toxigenic c difficile by the cepheid nucleic amplification assay am rapid respiratory viral screen culture right middle lobe respiratory viral culture preliminary respiratory viral antigen screen final negative for respiratory viral antigen specimen screened for adeno parainfluenza influenza a b and rsv by immunofluorescence refer to respiratory viral culture and or influenza pcr results listed under other tab for further information imaging cxr extensive multi lobar interstitial opacities with background ground glass opacities bilaterally with volume loss suggestive of infectious or inflammatory etiology correlate with outside hospital course prior disease and sputum culture ct chest parenchyma no air trapping noted again seen is mild centrilobular emphysema unchanged since prior comparison to there are multiple new subpleural interstitial opacities with associated honeycombing and more confluent components involving the lower lobes and lingula airways diffuse bronchial wall thickening predominantly involving the upper and central airways is unchanged consistent with small airways disease the airways are otherwise patent to the subsegmental level there is mild central and right lower lobe traction bronchiectasis no evidence of tracheobronchiomalacia on expiratory phase vessels thoracic aorta and main pulmonary artery are normal caliber chest cage no focal lytic or blastic lesions worrisome for malignancy no acute fracture impression findings suspicious for idiopathic pulmonary fibrosis mild centrilobular emphysema small airways disease cxr impression comparison with the study of there has been substantial clearing of the diffuse interstitial disease involving both lungs however there still is a substantial residual of interstitial fibrosis no evidence of acute focal consolidation discharge 05am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 05am blood glucose urean creat na k cl hco3 angap 05am blood crp brief hospital course this is a year old male with past medical history of cad with prior vt arrest diabetes type recent diagnosis of interstitial lung disease admitted with progressively worsening hypoxia thought to be possible cryptogenic organizing pneumonia course complicated by cdiff colitis treated with antibiotics for cdiff and steroids for cop with improving stool output and respiratory status able to be discharged home with oxygen acute issues addressed acute hypoxemic respiratory failure crypotgenic organizing pneumonia copd patient with recent history notable for post operative respiratory failure at initially attributed to bacterial pneumonia after an extensive workup who presented to days following his discharge with worsening dyspnea cough and hypoxia with cross sectional imaging with increased ggos and reticular opacities suggestive of interval progression of an interstitial process workup from was reviewed and pulmonary service was consulted bronchoscopy with bal was performed without evidence of infection imaging was felt to be consistent with cryptogenic organizing pneumonia once infection was ruled out and his cdiff was controlled as below patient was placed on high dose steroids with subsequent slow response over ensuing days discharged patient on prednisone as well as bactrim and ppi prophylaxis continued home spiriva and advair discharged home on 2l o2 c diff colitis course complicated by loose stools with positive c diff pcr assay infection was thought to be due to recent antibiotics course following surgery patient was started on po vancomycin with improvement discharged to complete po vancomycin course type diabetes metformin was initially held while he was acutely ill then restarted would follow up outpatient blood sugars to ensure continued control while on steroids cad s p stenting history of ventricular tachycardia patient continued on home aspirin brilinta and atorvastatin amiodarone was stopped due to concerns for pulmonary toxicity patient should follow up with cardiologist regarding discontinuation of amiodarone htn patient continued home ramipril gerd continued home omeprazole mg po bid anxiety continue home diazepam mg po qid prn anxiety transitional issues medications stopped amiodarone would consider alternate antiarrhythmic medications started prednisone mg daily bactrim ds daily calcium and vitamin d po vancomycin 125mg q6h through pt should continue on prednisone mg daily until directed to change dosing as per pulmonary team per pulmonary service request would consider outpatient dexa scan pulmonary follow up is being scheduled medications on admission the preadmission medication list is accurate and complete metoprolol succinate xl mg po daily ramipril mg po daily omeprazole mg po bid metformin xr glucophage xr mg po daily tudorza pressair aclidinium bromide mcg actuation inhalation daily fluticasone salmeterol diskus inh ih bid diazepam mg po q6h prn anxiety ticagrelor mg po bid aspirin mg po daily atorvastatin mg po qpm amiodarone mg po daily discharge medications albuterol inhaler puff ih q6h prn shortness of breath rx albuterol sulfate proventil hfa mcg puffs inh q6hr prn disp inhaler refills calcium d d3 calcium carbonate vitamin d3 mg 250mg unit oral daily rx calcium carbonate vitamin d3 calcium d mg calcium mg unit tablet s by mouth daily disp tablet refills prednisone mg po daily rx prednisone mg tablet s by mouth daily disp tablet refills sulfameth trimethoprim ds tab po daily rx sulfamethoxazole trimethoprim bactrim ds mg mg tablet s by mouth daily disp tablet refills vancomycin oral liquid mg po q6h rx vancomycin mg ml ml by mouth every six hours disp applicatorful refills aspirin mg po daily atorvastatin mg po qpm diazepam mg po q6h prn anxiety fluticasone salmeterol diskus inh ih bid metformin xr glucophage xr mg po daily metoprolol succinate xl mg po daily omeprazole mg po bid ramipril mg po daily ticagrelor mg po bid tudorza pressair aclidinium bromide mcg actuation inhalation daily equipment rolling walker dx hypoxemic respiratory failure px good 3months pulmonary rehab icd cryptogenic organizing pneumonia evaluate and treat discharge disposition home with service facility acute hypoxic respiratory failure secondary to cryptogenic organizing pneumonia cdiff colitis coronary artery disease s p stenting hypertension gastroesphageal reflux anxiety discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr it was a pleasure to care for you at why was i admitted to the hospital you were admitted to the hospital because you were having trouble breathing at home what was done for me while i was the hospital our pulmonary team evaluated you we took an image of your chest which showed scarring of your lungs we completed a procedure called a bronchoscopy which gave us a sample of what is your lungs you were started on a medication called prednisone to treat the inflammation your lungs and improved over the course of your hospital stay we stopped your amiodarone because it may affect your lungs you had an infection your stool from a bacteria called c difficile which should be continued for a total of days we placed you on an antibiotic bactrim to protect your lungs against a lung infection while you are on high dose steroids you should continue to take calcium and vitamin d to help keep your bones strong while taking steroids what should i do when i leave the hospital do not take amiodarone continue on your prednisone mg daily continue taking your other medications as prescribed see below we wish you the best your treatment team followup instructions

name unit no admission date discharge date date of birth sex m service surgery allergies no known allergies adverse drug reactions attending chief complaint type 1a endoleak with sac expansion s p prior evar major surgical or invasive procedure extension of prior evar history of present illness yo m with significant sac expansion of aaa to 8cm previously year ago pt denies any abdominal or back pain of note he had evar in followed by r hypogastric embolization and limb extension in past medical history pmh htn hld pre dm cad psh evar r limb extension lap chole t a social history family history brother diabetes mother cad heart failure physical exam physical exam vs t bp hr rr o2 sat ra general x nad a o x intubated sedated abnormal cv x rrr irregularly irregular no mrg nl s1s2 abnormal pulm cta b l x no respiratory distress abnormal abd x soft x nontender appropriately tender x nondistended no rebound guarding abnormal wound x cd i x no erythema induration x bilateral groin sites w dermabond soft no hematoma abnormal extremities x no cce abnormal pulses r p p p p l p p p p pertinent results admission labs 21pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 40am blood 21pm blood glucose urean creat na k cl hco3 angap 21pm blood calcium phos mg discharge labs 10am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 10am blood glucose urean creat na k cl hco3 angap 10am blood calcium phos mg brief hospital course patient is an yo m s p prior evar with type ia endoleak with sac expansion the patient presented to on and underwent extension of his prior evar with a cuff procedure uncomplicated and the patient was extubated post operatively and went to the pacu in good condition after a brief uneventful stay in the pacu the patient was transported to the floor in good condition for overnight observation from the evening of pod into the morning of pod the patient was noted to be hypertensive to sbp 160s 170s requiring pushes of hydralazine iv once and metoprolol tartrate iv x4 his outpatient cardiologist was contacted on the morning of pod for recommendations on medication changes but both he and his np were out of the office the patient was given a one time dose of atenolol mg po in addition to his home dose of mg bid and close follow up was arranged with his cardiologist on for bp check his home warfarin was also restarted on pod without any bridging the patient was otherwise doing well and deemed ready for discharge from the hospital at the time of discharge the patient was doing well afebrile with stable vital signs the patient was tolerating a regular diet ambulating voiding without assistance and pain was well controlled the patient was discharged home without services the patient received discharge teaching and follow up instructions with understanding verbalized and agreement with the discharge the patient was discharged on his home warfarin and asa daily and will follow up with dr in clinic in the next month medications on admission the preadmission medication list is accurate and complete lisinopril mg po daily allopurinol mg po daily atenolol mg po bid digoxin mg po daily warfarin mg po daily16 simvastatin mg po qpm isosorbide mononitrate mg po daily nitroglycerin sl mg sl q5min prn chest pain flaxseed oil tsp oral daily potassium chloride meq po daily aspirin mg po daily tamsulosin mg po qhs hydrochlorothiazide mg po daily trimethoprim mg po q24h ergocalciferol vitamin d2 mcg unit oral every other discharge medications allopurinol mg po daily aspirin mg po daily atenolol mg po bid digoxin mg po daily ergocalciferol vitamin d2 mcg unit oral every other flaxseed oil tsp oral daily hydrochlorothiazide mg po daily isosorbide mononitrate mg po daily lisinopril mg po daily nitroglycerin sl mg sl q5min prn chest pain potassium chloride meq po daily hold for k simvastatin mg po qpm tamsulosin mg po qhs trimethoprim mg po q24h warfarin mg po daily16 discharge disposition home discharge diagnosis type 1a endoleak with sac expansion s p prior evar discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr it was a pleasure taking care of you at you were admitted to the hospital after adjustment of a previously placed 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 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 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 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 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 followup instructions

name unit no admission date discharge date date of birth sex m service cardiothoracic allergies no known allergies adverse drug reactions attending chief complaint fatigue otherwise asymptomatic major surgical or invasive procedure coronary artery bypass graft x4 left internal mammary artery to left anterior descending artery and saphenous vein grafts to diagonal obtuse marginal and posterior descending arteries history of present illness year old male who originally presented to in with severe abdominal pain was found to have diverticulitis with an abscess he was initially treated with ivf for several days but developed pnd and chest congestion he was treated with iv diuretics with improvement he underwent a colostomy hopefully temporary with possible reversal in an echocardiogram was obtained and revealed a reduced lvef of he was sent for a nuclear stress test which demonstrated a severe inferolateral defect and lvef of he was started on lisinopril and metoprolol which has since been changed to coreg due to the findings on his stress test he was referred for a cardiac catheterization to further evaluate he was found to have multivessel disease and is now being referred to cardiac surgery to evaluate for surgical revascularization past medical history chf newly diagnosed diabetes mellitus hyperlipidemia ulcerative colitis diverticulitis with abscess s p colostomy anxiety insomnia depression rheumatic fever at age treated with penicillin until age past surgical history colostomy eye lift hypospadias s p repair social history family history family history premature coronary artery disease father had rheumatic fever as a child died of mi at age physical exam admit pe pulse resp o2 sat ra b p right left height weight kg general skin dry x intact x heent perrla x eomi x neck supple full rom x chest lungs clear bilaterally x heart rrr x irregular murmur grade abdomen soft x non distended x non tender x bowel sounds extremities warm x well perfused x edema varicosities none neuro grossly intact pulses femoral right p left p dp right p left p right p left p radial right p left p carotid bruit right left pertinent results admit labs 41am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 41am blood ptt 40pm blood urean creat na k cl hco3 angap 30pm blood mg studies cardiac catheterization is normal lad has moderate disease in the mid segment of the vessel the diagonal has severe disease in the proximal to mid segment of the vessel lcx is totally occluded with left to left collaterals filling the distal part of the vessel retrogradely rca is a dominant vessel with severe stenosis two tandem lesions and in the mid and distal segments of the vessel the distal stenosis is at the trifurcation of the distal right coronary artery posterior descending artery pda and posterolateral pl branch the pda and pl arteries fill retrogradely via left to right collaterals cardiac is mildly enlarged lv is mildly enlarged lvef grade iii diastolic dysfunction rv is normal size trace mr valve is there appears to be a calcified nodular appearance to the non coronary cusp consider healed vegetation calcified leaflet or other mass no ai aortic root is normal size other diagnostics nuclear stress test at large sized perfusion abnormality involving the inferior inferolateral and lateral walls consistent with infarct with mild infarct ischemia severe lv dysfunction with inferior hypokinesis lvef intraop tee conclusions prebypass no atrial septal defect is seen by 2d or color doppler left ventricular wall thicknesses are normal the left ventricular cavity is moderately dilated there is moderate regional left ventricular systolic dysfunction with inferior and inferolateral hypokinesis right ventricular chamber size and free wall motion are normal there are simple atheroma in the descending thoracic aorta the aortic valve leaflets are mildly thickened there is no aortic valve stenosis no aortic regurgitation is seen the mitral valve leaflets are mildly thickened mild to moderate mitral regurgitation is seen with restricted posterior mitral leaflet there is no pericardial effusion these findings were discussed with dr at the time of exam in the operating room postbypass the patient is a paced on a phenylephrine infusion no new regional wall motion abnormalities ef is mitral regurgitation is aortic contours are intact following decannulation the rest of the exam is unchanged from prebypass 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 36am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 12am blood 36am blood ptt 00am blood glucose urean creat na k cl hco3 angap 59pm blood glucose urean creat na k cl hco3 angap brief hospital course the patient was brought to the operating room on where the patient underwent coronary artery bypass graft x4 left internal mammary artery to left anterior descending artery and saphenous vein grafts to diagonal obtuse marginal and posterior descending arteries overall the patient tolerated the procedure well and post operatively was transferred to the cvicu in stable condition for recovery and invasive monitoring pod found the patient extubated alert and oriented and breathing comfortably the patient was neurologically intact and hemodynamically stable but required additional time with vasopressor support chest tubes were removed without problems he developed symptomatic rapid atrial fibrillation on pod and converted to sinus rhythm after iv amiodarone and beta blocker was initiated after receiving 1urbc for postop anemia he developed flash pulmonary edema and required bipap support he responded will to diuretics and was transitioned to hiflo nasal cannula and eventual traditional nasal cannula oxygen support his pacing wires were discontinued without complication given his ischemic cardiomyopathy ef his lisinopril was restarted lisinopril was subsequently discontinued due to hypotension he was transferred to the telemetry floor for further recovery the patient was evaluated by the physical therapy service for assistance with strength and mobility by the time of discharge on pod the patient was ambulating freely the wound was healing and pain was controlled with oral analgesics the patient was discharged to home with in good condition with appropriate follow up instructions medications on admission testosterone bulk pumps miscellaneous daily lisinopril mg po daily zaleplon mg oral qhs prn insomnia nicotine patch mg td daily alprazolam mg po bid prn anxiety carvedilol mg po bid metformin glucophage mg po bid atorvastatin mg po qpm nitroglycerin sl mg sl q5min prn chest pain aspirin mg po daily discharge medications alprazolam mg po bid prn anxiety rx alprazolam mg tablet s by mouth twice a day disp tablet refills aspirin mg po daily atorvastatin mg po qpm carvedilol mg po bid rx carvedilol mg tablet s by mouth twice a day disp tablet refills metformin glucophage mg po bid zaleplon mg oral qhs prn insomnia senna mg po bid rx sennosides senna mg by mouth twice a day disp tablet refills tramadol mg po q4h prn pain rx tramadol mg tablet s by mouth every four hours disp tablet refills amiodarone mg po bid bid x days then 400mg daily x days then 200mg daily rx amiodarone mg tablet s by mouth twice a day disp tablet refills potassium chloride meq po daily duration days rx potassium chloride meq tablet s by mouth daily disp tablet refills docusate sodium mg po bid hold for loose stool rx docusate sodium mg capsule s by mouth twice a day disp capsule refills furosemide mg po daily duration days rx furosemide mg tablet s by mouth daily disp tablet refills discharge disposition home with service facility discharge diagnosis cad s p revascularization brief postop atrial fibrillation pmh chf newly diagnosed diabetes mellitus hyperlipidemia ulcerative colitis diverticulitis with abscess s p colostomy anxiety insomnia depression rheumatic fever at age treated with penicillin until age past surgical history colostomy eye lift hypospadias s p repair discharge condition alert and oriented x3 non focal ambulating gait steady sternal pain managed with oral analgesics sternal incision healing well no erythema or drainage left incision healing well no erythema or drainage edema trace discharge instructions please shower daily including washing incisions gently with mild soap no baths or swimming and look at your incisions please no lotions cream powder or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature these should be written down on the chart no driving for approximately one month and while taking narcotics will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than pounds for weeks please call with any questions or concerns followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies codeine curry leaf tree morphine penicillins attending chief complaint syncope major surgical or invasive procedure none history of present illness ms is a lady with a pmh significant for pancreatic who presents with syncope patient reports that on the morning of admission she developed dizziness after standing up to go to the bathroom she told her friend she was about to pass out and she was lowered to the floor patient then remember waking up as the emt s were loading her on her stretcher her friend reported that she passed out a second time and did not report any seizure like activity patient denies tongue biting head strike or loss of bowel or bladder continence the emts reported that she was hypotensive on seen and gave her fluids in the field and placed her in r in the ed initial vs were t hr bp rr o2 on ra patient was given 2lns and bp s improved to s s initial labs were notable for nl chem wbc 1k hct plt trop negative x1 alp otherwise nl lft s ua unremarkable lactate ct a p redemonstrated known pancreatic mass with no acute process cxr showed no acute process patient was given 1g iv vancomycin and admitted to oncology for further management on arrival to the floor patient reports chronic abdominal pain similar to her prior pain she also has a chronic productive cough she has no other acute complaints she did have an episode of explosive diarrhea on prior to admission no bowel movements since then she denies fevers or chills no headache no dysphagia she has mild odynophagia from some op ulcers no cp or palpiatiations no sob or pleuritic pain no nausea or vomiting episode of diarrhea as above no personal or family history of dvt no recent travel no leg pain or swelling she did receive neulasta on remainder of ros is unremarkable past medical history past oncologic history evaluated by pcp umbilical hernia and gi distress on exam there was no mass that was able to be palpated so an ultrasound was recommended the ultrasound showed a x cm solid well circumscribed mass in the posterior abdomen versus retroperitoneum versus pancreatic head with adjacent adenopathy she then underwent an abdominal ct on which demonstrated a cm mass in the pancreas uncinate process suspicious for carcinoma she underwent an endoscopic ultrasound showed a x mm ill defined mass in the head of the pancreas the mass was hypoechoic and heterogeneous in texture the borders were irregular and poorly defined both an fna and fnb were performed but unfortunately they were nondiagnostic withscant parenchymal sampling stromal fibrosis and atypical ductal cells seen the initial ultrasound showed that the celiac artery takeoff and superior mesenteric artery takeoff were not invaded by the mass the mass also did not seem to involve the portal vein or a portosplenic confluence however it was in close proximity to the smv though there was an intact interface noted at all levels she returned for a second endoscopic ultrasound on and this time pathology from this biopsy showed pancreatic ductal adenocarcinoma moderately differentiated cytology was also suspicious for malignancy she saw dr and recommended neoadjuvant chemotherapy and cyberknife c1d1 folfirinox c2d1 folfirinox c3d1 folfirinox past medical history chronic low back pain bipolar disorder ptsd anxiety and panic disorder hyperthyroidism s p surgery hypothyroidism gerd irritable bowel syndrome osteoporosis palpitations prior myocarditis s p appendectomy s p thyroidectomy s p total abdominal hysterectomy in due to abnormal vaginal bleeding s p c section x s p bladder suspension s p tonsillectomy and adenoidectomy social history family history her birth mother had breast cancer at an unknown age her sister was diagnosed with breast cancer at age she has two maternal uncles who died of colon cancer one in his and one in his she has a maternal aunt who had ovarian cancer in her and her maternal grandmother also had breast cancer she states that she has met with a genetic counselor in the past and was told that she was at high risk for ovarian cancer but does not remember any blood work being done when they did her hysterectomy they also took out her ovaries physical exam admission physical exam vs t hr bp rr sat o2 on ra general pleasant lying in bed comfortably heent anicteric sclerae perll eomi op clear no lad cardiac regular rate and rhythm faint s1s2 no murmurs rubs or gallops lung appears in no respiratory distress clear to auscultation bilaterally no crackles wheezes or rhonchi abd normal bowel sounds soft ttp ruq no sign nondistended no hepatomegaly no splenomegaly ext warm well perfused no lower extremity edema pulses radial pulses pulses dp pulses neuro alert oriented cn ii xii intact motor and sensory function grossly intact ftn intact skin no significant rashes discharge physical exam vs ra general pleasant lying in bed comfortably heent anicteric sclerae perll eomi op clear no lad cardiac regular rate and rhythm no murmurs rubs or gallops lung appears in no respiratory distress clear to auscultation bilaterally abd normal bowel sounds soft ttp ruq nondistended no hepatomegaly no splenomegaly ext warm well perfused no lower extremity edema neuro alert oriented motor and sensory function grossly intact pertinent results admission labs 50pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 50pm blood neuts bands lymphs monos eos baso myelos absneut abslymp absmono abseos absbaso 50pm blood plt smr low plt 50pm blood ptt 50pm blood glucose urean creat na k cl hco3 angap 50pm blood alt ast alkphos totbili 50pm blood ctropnt 05am blood ck mb ctropnt 50pm blood albumin calcium phos mg 50pm blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg 01pm blood lactate discharge labs 05am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 05am blood glucose urean creat na k cl hco3 angap 05am blood alt ast ld ldh alkphos totbili 05am blood calcium phos mg studies imaging chest pa lat no acute cardiopulmonary process imaging cta abd pelvis mass centered in the uncinate process of the pancreas which is unchanged from exam days prior no evidence of acute intra abdominal process ekg nsr at lad with lafb anterior qwave no concerning st changes compared to ekg at is similar micro blood and urine cultures pending cdiff negative brief hospital course woman with pmh significant for bipolar disorder anxiety chronic pain hypothyroidism and pancreatic cancer currently on folfirinox cycle day who presented with syncope syncope patient with orthostasis at home and hypotensive on arrival to ed she had signs of dehydration elevated urine specific gravity fluid responsiveness she received 3l ivf with improvement of her symptoms laboratory workup only significant for leukocytosis in setting of recently receiving neulasta on many sedating medications at home but no new medication changes infectious workup negative negative ua cxr abd pelvis ct no n v diarrhea ekg w o ischemic changes and negative troponins x2 her primary oncologist was emailed she may need iv fluids after chemotherapy in the future to prevent dehydration she was discharged home with pcp and oncology follow up leukocytosis likely due to recent neulasta no signs of infection initially started on flagyl due to concerns for possible diarrheal infection but stopped before discharge given negative c diff and normal bowel movements during admission chronic issues abdominal pain chronic due to pancreatic cancer continued on her home oxycontin and oxycodone pancreatic cancer currently c3 folfirinox with planned stereotactic body radiotherapy with hope to become surgical candidate she will follow up with her outpatient oncologist hx of bipolar disorder anxiety continued home medications of abilify lamotrigine clonazepam trazodone hypothyroidism continued home levothyroxine hyperlipidemia continued home atorvastatin transitional issues blood and urine cx pending at discharge benefit from iv fluids after chemotherapy to prevent dehydration medications on admission the preadmission medication list is accurate and complete albuterol inhaler puff ih q4h prn sob aripiprazole mg po daily atorvastatin mg po qpm clonazepam mg po tid prn anxiety cyclobenzaprine mg po tid prn back pain dexilant dexlansoprazole mg oral daily lamotrigine mg po qam lamotrigine mg po qhs levothyroxine sodium mcg po daily levothyroxine sodium mcg po 1x week levothyroxine sodium mcg po 1x week sa ondansetron mg po q8h prn nausea oxycodone immediate release mg po q6h prn pain oxycodone sr oxycontin mg po q12h pregabalin mg po tid ranitidine mg po bid trazodone mg po qhs prn insomnia docusate sodium mg po bid discharge medications albuterol inhaler puff ih q4h prn sob aripiprazole mg po daily atorvastatin mg po qpm clonazepam mg po tid prn anxiety cyclobenzaprine mg po tid prn back pain docusate sodium mg po bid lamotrigine mg po qam lamotrigine mg po qhs levothyroxine sodium mcg po daily levothyroxine sodium mcg po 1x week oxycodone immediate release mg po q6h prn pain oxycodone sr oxycontin mg po q12h pregabalin mg po tid ranitidine mg po bid trazodone mg po qhs prn insomnia dexilant dexlansoprazole mg oral daily levothyroxine sodium mcg po 1x week sa ondansetron mg po q8h prn nausea discharge disposition home discharge diagnosis primary syncope dehydration secondary chronic low back pain bipolar disorder anxiety hypothyroidism gerd discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms it was a pleasure taking care of you during your stay you were admitted after you fainted at home your blood pressure was low on admission and you had signs of dehydration you were given iv fluids with improvement of your symptoms infectious workup was negative and heart monitoring was also unrevealing try to eat and drink well at home you may need iv fluids after your chemotherapy in the future please follow up with your pcp and oncologist after discharge we wish you the best your care team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies codeine curry leaf tree morphine penicillins attending chief complaint abdominal pain major surgical or invasive procedure celiac plexus block history of present illness ms is a pleasant undomiciled with multiple anxiety disorders and locally advanced pancreatic cancer currently on neoadjuvant folfirinox last administered c515 on today c5d26 who is p w two weeks of uncontrollable nausea vomiting abd pain she states her symptoms started w nausea and severe abdominal pain around her epigastric area and ruq area just prior to her cycle of chemo pain did not radiaate was constant spikes and had no alleviating or provoking factors she was admitted to on sat where she had a ct which revealed a pancreatic mass of x mm previously in our records x she was managed conservatively with ivf zofran and her symptoms improved per the d c summary she was maintained on a soft diet which she tolerated well pt notes that her symptoms never improved and after leaving the hospital she presented to our ed she denied any f c no vomiting nausea no bm in several days but just had one on admission and described it as formed has some chest tightness and sob from chronic bronchitis but no current change from baseline she notes food does not alleviate nor provoke her symptoms old records alk phos showed no definite acute abdominal process lung nodules pancreatic mass lle us no dvt she last saw dr on at which point she had reported syncope a few days prior this seemed like an isolated incident ekg was stable from prior apparently she has been staying at a ed course t hr bp rr ra bp as low as got 1l ivf also given total 3mg iv dilaudid given total 8mg iv zofran and meq potassium labs with k otherwise chem reassuring except alk phos hct wbc plts lipase admitted for decreased po intake pain and nausea review of systems point ros negative except for what is mentioned above past medical history past oncologic history per omr evaluated by pcp umbilical hernia and gi distress on exam there was no mass that was able to be palpated so an ultrasound was recommended the ultrasound showed a x cm solid well circumscribed mass in the posterior abdomen versus retroperitoneum versus pancreatic head with adjacent adenopathy she then underwent an abdominal ct on which demonstrated a cm mass in the pancreas uncinate process suspicious for carcinoma she underwent an endoscopic ultrasound showed a x mm ill defined mass in the head of the pancreas the mass was hypoechoic and heterogeneous in texture the borders were irregular and poorly defined both an fna and fnb were performed but unfortunately they were nondiagnostic withscant parenchymal sampling stromal fibrosis and atypical ductal cells seen the initial ultrasound showed that the celiac artery takeoff and superior mesenteric artery takeoff were not invaded by the mass the mass also did not seem to involve the portal vein or a portosplenic confluence however it was in close proximity to the smv though there was an intact interface noted at all levels she returned for a second endoscopic ultrasound on and this time pathology from this biopsy showed pancreatic ductal adenocarcinoma moderately differentiated cytology was also suspicious for malignancy she saw dr and recommended neoadjuvant chemotherapy and cyberknife c1d1 folfirinox c2d1 folfirinox c3d1 folfirinox past medical history per omr chronic low back pain bipolar disorder ptsd anxiety and panic disorder hyperthyroidism s p surgery hypothyroidism gerd irritable bowel syndrome osteoporosis palpitations prior myocarditis social history family history her birth mother had breast cancer at an unknown age her sister was diagnosed with breast cancer at age she has two maternal uncles who died of colon cancer one in his and one in his she has a maternal aunt who had ovarian cancer in her and her maternal grandmother also had breast cancer she states that she has met with a genetic counselor in the past and was told that she was at high risk for ovarian cancer but does not remember any blood work being done when they did her hysterectomy they also took out her ovaries physical exam admission physical exam vital signs ra general nad heent mmm no op lesions no cervical supraclavicular or axillary adenopathy no thyromegaly cv rr nl s1s2 no s3s4 mrg pulm ctab gi bs soft ttp to deep palpation epigastric and ruq area no masses or hepatosplenomegaly limbs no edema clubbing tremors or asterixis no inguinal adenopathy skin no rashes or skin breakdown neuro grossly intact discharge exam vital signs t bp hr rr o2 ra general pleasant woman sitting up in bed nad cv rr nl s1s2 pulm nonlabored appearing on ra ctab gi soft mildly tender in epigastrium non tender in rlq and llq no sign nabs nondistended limbs no neuro alert and oriented no focal deficits pertinent results pertinent imaging imaging cta abd pelvis no evidence of acute intra abdominal process unchanged appearance of hypo attenuating uncinate process pancreatic mass with encasement of an early branch of the sma no abnormal bowel wall enhancement or pneumatosis right lower lobe areas of opacity suggesting either aspiration or early infection imaging gastric emptying study findings residual tracer activity in the stomach is as follows at mins of the ingested activity remains in the stomach at hours of the ingested activity remains in the stomach at hours of the ingested activity remains in the stomach at hours of the ingested activity remains in the stomach the emptying curve demonstrates a plateau for the first minutes followed by markedly slow emptying for the remainder of the exam no reflux to the esophagus impression markedly abnormal gastric emptying study with the majority of activity remaining in the stomach imaging chest pa lat the cardiomediastinal silhouette is normal the hila are normal there is a large region of heterogeneous opacity extending from the mid lower to upper lung zone likely representing pneumonia no pleural abnormalities no pneumothorax the visualized bones and soft tissues are normal the right port is in satisfactory position bd pelvis with co no significant interval changes in an uncinate process pancreatic lesion encasing and occluding an early branch of the sma no abnormal wall enhancement noted significant amount of residual dense oral contrast in the rectum and sigmoid colon since last study raises concern for barium impaction persistent nodules in the right lower and right middle lobes are likely due to aspiration unchanged mm left lower lobe lung nodule should be reassessed at the time of the follow up imaging chest portable ap compared to chest radiographs and heterogeneous peribronchial opacification in the right lung has improved consistent with decreasing pneumonia left lung clear no pleural abnormality normal cardiomediastinal silhouette right transjugular central venous infusion catheter ends in the low svc admission blood work 50pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 05am blood ptt 50pm blood glucose urean creat na k cl hco3 angap 50pm blood alt ast alkphos totbili 50pm blood lipase 32am blood albumin calcium phos mg 33am blood lactate discharge blood work 49am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 49am blood glucose urean creat na k cl hco3 angap 34pm blood alt ast ck cpk alkphos totbili 49am blood calcium phos mg 05am blood lactate micro blood culture blood culture routine pending inpatient blood culture blood culture routine pending inpatient blood culture blood culture routine pending inpatient urine urine culture final inpatient blood culture blood culture routine pending inpatient blood culture blood culture routine final inpatient blood culture blood culture routine final inpatient all negative to date brief hospital course principle reason for admission w locally advanced pancreatic cancer s p xrt on folfirinox f b neulasta upcoming whipple scheduled who p w weeks of persistent nausea and abdominal pain acute problems nausea vomiting abdominal pain gastroparesis fever etiology initially thought related to chemo given symptoms started shortly after folfirnox prior to admission ct scan unremarkable initially improved with ativan zofran zyprexa underwent celiac nerve block on symptoms recurred on the day of most recent folfirinox chemotherapy that same day also had a markedly positive gastric emptying study she was started on metoclopramide on and erythromycin on with good response erythromycin was discontinued on nd prevent tachyphlyaxis of note her abilify was discontinued as it interacts with the metoclopramide other interventions included increasing home oxycontin to 20mg twice daily fosprepitent with chemotherapy d1 added creon to meals added bid ppi in place of h2 blocker and increased bowel regimen despite this patient continued to have significant nausea and vomiting with meals patient developed a fever on and ct abdomen pelvis on revealed oral barium impaction patient underwent enema that night with output of barium contrast and solid stool patient s nausea and vomiting improved significantly but continued to have marked abdominal pain she did not have another bowel movement for the next two days aso underwent additional enema on again with good output shortly following second enema patient did develop feelings of presyncope and sbp s in the low s infectious and cardiac workup was unremarkable and patient responded quite well to 5l ns etiology thought due to hypovolemia and vagal stimulation from enema by day of discharge patient felt well without nausea or vomiting and significant improvement in her chronic abdominal pain which was well controlled with oral pain medications notably fever on thought due to aspiration as it resolved quickly without sigficant leukocytosis or antibiotics and resolving infiltrate on repeat cxr pancreatic cancer locally advanced and has demonstrated a favorable response to neoadjuvant chemotherapy plan to continue chemo when n v and abdominal pain improve and patient plans for on c6d1 folfirinox was given on with neulasta on c6d15 folfirinox was held and after discussion with patient s primary oncologist she will not undergo additional chemotherapy she will follow up with her outpatient oncologist and with her surgeon dr in preparation for whipple surgery at the end of this month depression anxiety symptoms were largely stable during admisison abilify was stopped due to interaction with metoclopramide patient should follow up with her outpatient psychiatry providers we continued her trazodone pregabalin lamotrigine and clonazepam qtc was monitored weekly last was 400msec on admit qtc was 420msec hypokalemia likely due to n v and chemotherapy resolved w repletion chronic problems borderline macrocytic anemia stable antineoplastic therapy thrombocytopenia stable antineoplastic therapy improved gerd switched to bid omeprazole and tums prn hypothyroid continued levothyroxine transitional issues maintain aggressive bowel regimen to prevent constipation obstipation monitor qtc intermittently while on standing metoclopramide would suggest doing this every for the next weeks adjust pain medications as needed follow up with surgery on for planning of whipple s p neoadjuvant folfirinox ensure follow up with her outpatient psychiatry providers rehab stay is less than days at this time greater than minutes were spent in planning and execution of this discharge medications on admission the preadmission medication list is accurate and complete albuterol inhaler puff ih q4h prn sob aripiprazole mg po daily atorvastatin mg po qpm clonazepam mg po tid anxiety cyclobenzaprine mg po tid prn back pain docusate sodium mg po bid lamotrigine mg po qam lamotrigine mg po qhs oxycodone immediate release mg po q6h prn pain pregabalin mg po tid ranitidine mg po bid trazodone mg po qhs insomnia ondansetron mg po q8h prn nausea discharge medications calcium carbonate mg po qid prn heartburn rx calcium carbonate mg calcium mg tablet s by mouth four times a day disp tablet refills creon cap po qidwmhs rx lipase protease amylase creon unit unit unit capsule s by mouth three times a day disp capsule refills lorazepam mg po tid rx lorazepam mg tab by mouth three times a day disp tablet refills metoclopramide mg po qidachs rx metoclopramide hcl mg tab by mouth three times a day disp tablet refills olanzapine disintegrating tablet mg po daily rx olanzapine mg tablet s by mouth daily disp tablet refills omeprazole mg po bid rx omeprazole mg capsule s by mouth twice a day disp capsule refills oxycodone sr oxycontin mg po q12h rx oxycodone oxycontin mg tablet s by mouth twice a day disp tablet refills polyethylene glycol g po daily rx polyethylene glycol miralax gram dose powder s by mouth daily refills oxycodone immediate release mg po q4h prn pain rx oxycodone mg capsule s by mouth q4 hours disp capsule refills albuterol inhaler puff ih q4h prn sob rx albuterol sulfate proair hfa mcg puff ih q4 hours disp inhaler refills atorvastatin mg po qpm rx atorvastatin mg tablet s by mouth at bedtime disp tablet refills clonazepam mg po tid anxiety rx clonazepam mg tablet s by mouth three times a day disp tablet refills cyclobenzaprine mg po tid prn back pain rx cyclobenzaprine mg tablet s by mouth three times a day disp tablet refills docusate sodium mg po bid rx docusate sodium colace mg capsule s by mouth twice a day disp capsule refills lamotrigine mg po qam rx lamotrigine mg tablet s by mouth qam disp tablet refills lamotrigine mg po qhs rx lamotrigine mg tablet s by mouth at bedtime disp tablet refills levothyroxine sodium mcg po 5x week rx levothyroxine mcg tablet s by mouth daily disp tablet refills levothyroxine sodium mcg po 1x week sa levothyroxine sodium mcg po 1x week ondansetron mg po q8h prn nausea rx ondansetron mg tablet s by mouth q8 hours disp tablet refills pregabalin mg po tid rx pregabalin lyrica mg capsule s by mouth three times a day disp capsule refills trazodone mg po qhs insomnia rx trazodone mg tablet s by mouth at bedtime disp tablet refills discharge disposition extended care facility diagnosis pancreatic cancer abdominal pain gastroparesis fecal impaction 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 nausea and vomiting this was likely from a combination of as side effect of your chemotherapy gastroparesis slow emptying of the stomach and impaction of oral barium we started you on several medications to help improve your symptoms of gastroparesis and we gave you two enemas to help clear out the impaction afterward your symptoms significantly improved you received your last dose of chemotherapy on we held the dose you will follow up with your primary care doctor and with dr as below before meeting with dr on in preparation for your surgery late this month sincerely your care team followup instructions

name unit no admission date discharge date date of birth sex f service surgery allergies codeine curry leaf tree morphine penicillins attending chief complaint pancreatic cancer major surgical or invasive procedure open cholecystectomy gastrojejunostomy history of present illness ms is a with a history of anxiety and gerd who p w pancreatic adenocarcinoma on neoadjuvant folfirinox therapy patient was evaluated by dr possible resection she present today for elective surgical procedure past medical history chronic low back pain bipolar disorder ptsd anxiety and panic disorder hyperthyroidism s p surgery hypothyroidism gerd irritable bowel syndrome osteoporosis palpitations prior myocarditis pancreatic adenocarcinoma s p neoadjuvant therapy social history family history her birth mother had breast cancer at an unknown age her sister was diagnosed with breast cancer at age she has two maternal uncles who died of colon cancer one in his and one in his she has a maternal aunt who had ovarian cancer in her and her maternal grandmother also had breast cancer she states that she has met with a genetic counselor in the past and was told that she was at high risk for ovarian cancer but does not remember any blood work being done when they did her hysterectomy they also took out her ovaries physical exam prior to discharge vs ra gen anxious female with nad cv rrr no m r g pulm diminished bs bilaterally on bases abd bilateral subcostal incision open to air with staples middle and left lateral aspect with openings packed with moist to dry gauze with minimal surrounding erythema no purulent drainage or odor extr warm no c c e pertinent results rercent labs 38am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood glucose urean creat na k cl hco3 angap 00am blood calcium phos mg micro time taken not noted log in date time pm swab source wound source wound final report wound culture final klebsiella pneumoniae sparse growth cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h sensitivities mic expressed in mcg ml klebsiella pneumoniae ampicillin sulbactam s cefazolin s cefepime s ceftazidime s ceftriaxone s ciprofloxacin s gentamicin s meropenem s piperacillin tazo s tobramycin s trimethoprim sulfa s radiology cxr impression new infiltrates consistent with pneumonitis in the appropriate clinical setting brief hospital course the patient with pancreatic adenocarcinoma s p neoadjuvant therapy was admitted to the hpb surgical service for elective procedure on the patient went in or for planned operation during the case she was found to have unresectable disease she underwent open cholecystectomy and palliative gastrojejunostomy 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 with ngt on iv fluids with a foley catheter and epidural catheter for pain control the patient was hemodynamically stable neuro the patient received epidural analgesia immediately post op with good effect and adequate pain control her epidural fell out on pod and patient was transitioned to dilaudid pca when tolerating oral intake the patient was transitioned to oral pain medications including her home dose oxycontin patient has a history of anxiety and takes clonazepam mg tid at home post operatively she was started on iv lorazepam when tolerating po she was switched to home dose clonazepam cv the patient remained stable from a cardiovascular standpoint vital signs were routinely monitored pulmonary patient has a history of copd she was required supplemental o2 post op overnight only to keep her o2 sat good pulmonary toilet early ambulation and incentive spirrometry were encouraged throughout hospitalization gi gu fen post operatively the patient was made npo with iv fluids diet was advanced when appropriate which was well tolerated patient s intake and output were closely monitored and iv fluid was adjusted when necessary electrolytes were routinely followed and repleted when necessary id the patient s white blood count and fever curves were closely watched for signs of infection on pod patient was noticed to have wound erythema wbc was elevated and she had low grade fever wound was partially opened and some purulent fluid was drained wound was packed with dry gauze patient was started on clindamycin erythema subsided would cultures were positive for pan sensitive klebsiella patient will complete days course of antibiotics endocrine no issues hematology the patient s complete blood count was examined routinely no transfusions were required prophylaxis the patient received subcutaneous heparin and venodyne boots were used during this stay was encouraged to get up and ambulate as early as possible prior to discharge patient was transitioned to prophylactic lovenox x days to prevent dvts at the time of discharge the patient was doing well afebrile with stable vital signs the patient was tolerating a regular diet ambulating voiding without assistance and pain was well controlled the patient received discharge teaching and follow up instructions with understanding verbalized and agreement with the discharge plan medications on admission albuterol sulfate inhaler 2puffs q4 6hrs prn dyspnea atorvastatin 20mg qhs benzonatate 100mg q8h prn clonazepam 1mg tid colace miralax creon caps qac cyclobenzaprine 10mg tid prn lamictal 100mg qam 200mg qpm levothyroxine 137mcg qd ipratropium albuterol neb q6h prn nexium 40mg bid oxycodone q6h prn oxycontin 20mg q12h lyrica 200mg tid ranitidine 150mg bid trazodone 300mg qhs discharge medications acetaminophen mg po q8h do not exceed more then mg day clindamycin mg po q6h last day of this medication docusate sodium mg po bid enoxaparin sodium mg sc daily start today first dose next routine administration time metoclopramide mg po qidachs nexium esomeprazole magnesium mg oral bid polyethylene glycol g po daily prn constipation senna mg po bid atorvastatin mg po qpm clonazepam mg po tid creon cap po tid w meals ipratropium albuterol neb neb neb q6h prn sob lamotrigine mg po qam lamotrigine mg po qpm levothyroxine sodium mcg po daily oxycodone immediate release mg po q4h prn pain moderate oxycodone sr oxycontin mg po q12h pregabalin mg po tid trazodone mg po qhs discharge disposition extended care facility discharge diagnosis locally advanced pancreatic adenocarcinoma wound infection discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted to the surgery service at for surgical resection of your pancreatic mass intraoperative you were found to have locally advanced disease and you underwent open cholecystectomy and gastrojejunostomy your recovery was complicated by wound infection you are now safe to be discharge in rehabilitation to complete your recovery with the following instructions please call dr office at if you have any questions or concerns please resume all regular home medications unless specifically advised not to take a particular medication also please take any new medications as prescribed please get plenty of rest continue to ambulate several times per day and drink adequate amounts of fluids avoid lifting weights greater than lbs until you follow up with your surgeon who will instruct you further regarding activity restrictions avoid driving or operating heavy machinery while taking pain medications please follow up with your surgeon and primary care provider pcp as advised incision care your wound dressing will be changed by nurses twice day please call your doctor or nurse practitioner if you have increased pain swelling redness or drainage from the incision site avoid swimming and baths until your follow up appointment you may shower and wash surgical incisions with a mild soap and warm water gently pat the area dry if you have staples they will be removed at your follow up appointment followup instructions

name unit no admission date discharge date date of birth sex f service surgery allergies codeine morphine penicillins attending chief complaint fever hypotension major surgical or invasive procedure ultrasound guided drainage of cm collection within the gallbladder fossa history of present illness ms is a w pancreatic adeno s p neoadjuvant folfirinox and aborted whipple open ccy palliative gastro j on d c d she did require opening of portions of her surgical incision site due to concerns for infection at that time today she returns from her assisted living facility to the ed today for evaluation of fevers to per report as well as hypotension with reported sbp she presently denies significant abdominal pain and states that it is largely unchanged since the time of surgery she denies nausea vomiting change in bm erythema purulence from the wound site and any other systemic symptoms past medical history chronic low back pain bipolar disorder ptsd anxiety and panic disorder hyperthyroidism s p surgery hypothyroidism gerd irritable bowel syndrome osteoporosis palpitations prior myocarditis pancreatic adenocarcinoma s p neoadjuvant therapy social history family history her birth mother had breast cancer at an unknown age her sister was diagnosed with breast cancer at age she has two maternal uncles who died of colon cancer one in his and one in his she has a maternal aunt who had ovarian cancer in her and her maternal grandmother also had breast cancer she states that she has met with a genetic counselor in the past and was told that she was at high risk for ovarian cancer but does not remember any blood work being done when they did her hysterectomy they also took out her ovaries physical exam prior to discharge vs ra gen somewhat anxious without acute distress heent no scleral icterus cv rrr no m r g pulm diminished bs bilateral on bases abd subcostal incision open to air with steri strips both lateral aspects with moist to dry gauze dressing rlq drain to gravity drainage with small amount of serosanguinous drainage site c d i extr warm no c c e pertinent results recent labs 25am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 25am blood glucose urean creat na k cl hco3 angap 43am blood alt ast alkphos amylase totbili 25am blood calcium phos mg 53pm blood lactate microbiology am bile gram stain final per 1000x field polymorphonuclear leukocytes per 1000x field gram negative rod s fluid culture preliminary klebsiella pneumoniae moderate growth cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h sensitivities mic expressed in mcg ml klebsiella pneumoniae ampicillin sulbactam s cefazolin s cefepime s ceftazidime s ceftriaxone s ciprofloxacin s gentamicin s meropenem s piperacillin tazo s tobramycin s trimethoprim sulfa s anaerobic culture preliminary no anaerobes isolated radiology ct abd impression x x cm hypodense collection with mild peripheral rim enhancement in the gallbladder fossa which could be postoperative seroma biloma or abscess pancreatic mass in the uncinate process which abuts the sma proximal portion of the first smv branch and duodenum with surrounding fat stranding haziness as above appears slightly larger compared with left lower lobe pulmonary opacity is concerning for pneumonia mild interval increase in common bile duct dilation to mm without intrahepatic biliary ductal dilation moderate centrilobular emphysema mm right lower lobe pulmonary nodule close attention on follow up small hiatal hernia brief hospital course the patient s p palliative gastrojejunostomy and cholecystectomy on was re admitted to the hpb surgical service from rehab to evaluate new onset of fever and hypotension abdominal ct on admission revealed x x cm hypodense collection with mild peripheral rim enhancement in the gallbladder fossa concerning for intra abdominal abscess patient was started on clindamycin and radiology was consulted for possible drainage of the collection on hd patient underwent us guided drainage with placement of the catheter into collection fluid was sent for microbiology evaluation post procedure patient s diet was advanced to regular and was well tolerated her wbc started to downward on hd antibiotics were changed to cipro flagyl on hd patient spiked a fever she was pancultures wbc returned back to normal level on hd abscess cultures showed pan sensitive klebsiella she remained afebrile surveillance blood and urine cultures were negative patient was able to tolerated regular diet and pain was well controlled she was discharged back in rehabilitation on hd in stable condition at the time of discharge the patient was doing well afebrile with stable vital signs the patient was tolerating a regular diet ambulating voiding without assistance and pain was well controlled the patient received discharge teaching and follow up instructions with understanding verbalized and agreement with the discharge plan medications on admission acetaminophen mg po q8h do not exceed more then mg day clindamycin mg po q6h last day of this medication docusate sodium mg po bid enoxaparin sodium mg sc daily start today first dose next routine administration time metoclopramide mg po qidachs nexium esomeprazole magnesium mg oral bid polyethylene glycol g po daily prn constipation senna mg po bid atorvastatin mg po qpm clonazepam mg po tid creon cap po tid w meals ipratropium albuterol neb neb neb q6h prn sob lamotrigine mg po qam lamotrigine mg po qpm levothyroxine sodium mcg po daily oxycodone immediate release mg po q4h prn pain moderate oxycodone sr oxycontin mg po q12h pregabalin mg po tid trazodone mg po qhs discharge medications acetaminophen mg po q6h prn pain mild ciprofloxacin hcl mg po q12h last day of this medication enoxaparin sodium mg sc daily start today first dose next routine administration time last day of this medication metronidazole mg po q8h last day for this medication nexium esomeprazole magnesium mg oral daily atorvastatin mg po qpm clonazepam mg po tid prn anxiety creon cap po tid w meals docusate sodium mg po bid lamotrigine mg po qam lamotrigine mg po qpm levothyroxine sodium mcg po daily oxycodone immediate release mg po q4h prn pain severe oxycodone sr oxycontin mg po q12h pregabalin mg po tid senna mg po bid prn constipation trazodone mg po qhs discharge disposition extended care facility discharge diagnosis locally advanced pancreatic adenocarcinoma intra abdominal abscess discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted to the surgery service at for evaluation of high grade fever and hypotention abdominal ct scan revealed gallbladder fossa abscess you underwent us guided drainage of the abscess and were started on antibiotics you are now safe to return home to complete your recovery with the following instructions please call dr office at if you have any questions or concerns please resume all regular home medications unless specifically advised not to take a particular medication also please take any new medications as prescribed please get plenty of rest continue to ambulate several times per day and drink adequate amounts of fluids avoid lifting weights greater than lbs until you follow up with your surgeon who will instruct you further regarding activity restrictions avoid driving or operating heavy machinery while taking pain medications please follow up with your surgeon and primary care provider pcp as advised incision care please change dressing twice a day please call your doctor or nurse practitioner if you have increased pain swelling redness or drainage from the incision site avoid swimming and baths until your follow up appointment you may shower and wash surgical incisions with a mild soap and warm water gently pat the area dry if you have steri strips they will fall off on their own please remove any remaining strips days after surgery drain care flush and aspirate back with cc of ns twice a day please look at the site every day for signs of infection increased redness or pain swelling odor yellow or bloody discharge warm to touch fever if the drain is connected to a collection container please note color consistency and amount of fluid in the drain call the doctor or nurse if the amount increases significantly or changes in character be sure to empty the drain frequently record the output if instructed to do so wash the area gently with warm soapy water or strength hydrogen peroxide followed by saline rinse pat dry and place a drain sponge change daily and as needed keep the insertion site clean and dry otherwise avoid swimming baths hot tubs do not submerge yourself in water make sure to keep the drain attached securely to your body to prevent pulling or dislocation followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies penicillins attending chief complaint lower gi bleed major surgical or invasive procedure flexible sigmoidoscopy x2 history of present illness mr is a year old man with a history of cad s p cabg x3 in aortic stenosis s p aortic valve replacement htn ckd iii pulmonary sarcoidosis and gerd who is presenting with hematochezia the patient was in his usual health prior to presenting on for a routine screening colonoscopy he had a cm polyp removed via endoscopic mucosal resection emr once he returned at home after the procedure he had episodes of bright red blood covering his stool and in the toilet bowl without rectal pain or dark stools he had not had bloody stools beforehand he called the gi office who recommended that he go to the nearest ed he was then transferred from an ed in to he had no associated symptoms of lightheadedness vision changes syncope head strike chest pain palpitations or abdominal pain in the ed the patient s vitals were stable his exam was notable for bright red blood in the rectal vault but was otherwise normal labs including cbc had a hgb chem with cr baseline gi was consulted and performed a flexible sigmoidoscopy on which showed bleeding from the polyp removal site he received epinephrine injection and endoclips with adequate hemostasis postprocedurally he developed crampy abdominal pain with distension an abdominal x ray showed nonobstructive bowel gas pattern with an overall paucity of bowel gas due to his unrelenting pain he had a repeat flex sig which didn t identify perforation or repeat bleeding air was suctioned out after which his symptoms improved on repeat cbc h h with hgb drop from to and new leukocytosis to on arrival to the floor the patient is having dinner and feels well he is pain free and has not had any bloody bm over the last 24h he reminds me that he s a jehovah s witness and would not receive blood products should he need them past medical history cad s p cabg x3 in aortic stenosis s p bioprosthetic aortic valve replacement htn ckd iii pulmonary sarcoidosis gerd social history family history extensive history of heart disease in his immediate family no history of cancer particularly colon cancer physical exam admission vitals t bp hr rr o2 sat95 ra gen in nad heent perrl moist mucous membranes oropharynx clear without exudates neck no jvd no cervical lymphadenopathy cv rrr no murmurs gallops rubs pulm ctab no wheezing crackles rhonchi abd soft non tender non distended extrem no edema pulses p bilaterally skin no rashes neuro a ox3 cn ii xii intact motor and sensation grossly intact discharge hr data last updated temp po bp l lying hr rr o2 sat o2 delivery ra gen nad heent perrl no conjunctival pallor mmm oropharynx clear without exudates neck no jvd no cervical lymphadenopathy cv rrr no murmurs gallops rubs pulm ctab no wheezing crackles rhonchi abd soft non tender non distended slight ttp in rlq ruq and epigastric region extrem no edema pulses p bilaterally skin no rashes neuro a ox3 cn ii xii intact motor and sensation grossly intact pertinent results admission 21am wbc rbc hgb hct mcv mch mchc rdw rdwsd 21am neuts monos eos basos im absneut abslymp absmono abseos absbaso 21am glucose urea n creat sodium potassium chloride total co2 anion gap 21am calcium phosphate magnesium 48pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 48pm neuts lymphs monos eos basos im absneut abslymp absmono abseos absbaso discharge 47am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 08pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt imaging sigmoidoscopy a single oozing ulcer was found at the site of the previous emr polypectomy at 20cm 3ml of epi were injected and endoclips placed for hemostasis brief hospital course w pmh cad s p cabg as s p aortic valve replacement htn ckd iii pulmonary sarcoidosis and gerd p w hematochezia following screening colonoscopy underwent flexible sigmoidoscopy with epipherine injection and endoclips with adequate hemostasis he remained hemodynamically stable with a stable hgb and tolerated po well with bms with some dried blood but no fresh blood acute issues hematochezia abdominal pain patient originally presented with hematochezia following routine colonoscopy with polypectomy on and is now s p flexible sigmoidoscopy with successful hemostasis his vital signs remained stable and he had no signs or symptoms of significant volume loss his h h were stable of note the patient is s witness and doesn t accept blood transfusion leukocytosis patient with leukocytosis to while in ed he has been afebrile without evidence of active infection on exam likely reactive secondary to blood loss and endoscopy chronic stable issues cad s p cabg x3 in continued home metoprolol aspirin held while inpatient htn continued home amlodipine spironolactone pulmonary sarcoidosis continued home prednisone ckd iii cr at baseline this admission transitional issues discharge cr discharge hgb please obtain repeat cbc within one week to ensure stability and continue to monitor for signs of bleeding if stable recommend restarting aspirin no specific gi follow up needed outside of screening recommendations pending pathology report medications on admission the preadmission medication list is accurate and complete prednisone mg po every other day chlordiazepoxide mg po q8h prn anxiety metoprolol succinate xl mg po daily amlodipine mg po daily spironolactone mg po bid aspirin mg po daily vitamin d unit po daily discharge medications amlodipine mg po daily chlordiazepoxide mg po q8h prn anxiety metoprolol succinate xl mg po daily prednisone mg po every other day spironolactone mg po bid vitamin d unit po daily held aspirin mg po daily this medication was held do not restart aspirin until told by your pcp or cardiologist disposition home discharge diagnosis primary lower gi bleed from polypectomy site secondary coronary artery disease hypertension chronic kidney disease stage iii discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr it was a privilege caring for you at why was i in the hospital you had blood in your stool which was found to be caused by the site of your polyp removal during your colonoscopy what happened to me in the hospital the gi team went in an placed clips and injected medication to control the bleeding from in your colon you were watched carefully and had stable blood pressure heart rate and blood counts you had bowel movements with some dried blood in them but no fresh blood this is to be expected what should i do after i leave the hospital if you have another episode where you are filling the toilet bowl with fresh blood please go to the emergency room we recommend that you hold off on taking your aspirin for a short time please discuss with your pcp or cardiologist about restarting your aspirin at your follow up appointment continue to take all your medicines and keep your appointments we wish you the best sincerely your team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies no allergies adrs on file attending chief complaint syncope major surgical or invasive procedure none history of present illness ms is a healthy woman who presents with multiple syncopal episodes new onset atrial fibrillation with hrs in 100s 130s over the past week she has had syncopal episodes all episodes are without prodrome no preceding dizziness or lightheadness in the most recent episode on she stood up from her bed to walk to her dresser the next thing she knew she was on the floor after falling forward hitting her face and then losing consciousness no incontinence no confusion post fall earlier today she presented to her pcp and was found to have new onset atrial fibrillation with hrs in the 100s 130s she denies any fevers chest pain shortness of breath abdominal pain nausea vomiting diarrhea or dysuria in the ed initial vitals were ra ecchymosis tenderness over l orbital floor ekg af no ste std in v4 v6 labs studies notable for trop k na patient was given iv diltiazem mg po potassium chloride meq ivf meq potassium chloride ml ns po diltiazem mg vitals on transfer ra on the floor she feels very well no chest pain orthopnea shortness of breath palpitations or lightheadedness she says that doctors have known she has an irregular heart rhythm for years but she has never been diagnosed with afib and has never been on heart medications review of systems cardiac review of systems is notable for absence of chest pain dyspnea on exertion paroxysmal nocturnal dyspnea orthopnea ankle edema palpitations syncope or presyncope on further review of systems denies any prior history of stroke tia deep venous thrombosis pulmonary embolism bleeding at the time of surgery myalgias joint pains cough hemoptysis black stools or red stools denies exertional buttock or calf pain denies recent fevers chills or rigors all of the other review of systems were negative past medical history cardiac risk factors no htn dm or hld cardiac history cabg none percutaneous coronary interventions none pacing icd none other past medical history anxiety gerd social history family history mother died in her of cad otherwise no family history of early mi arrhythmia cardiomyopathies or sudden cardiac death physical exam admission physical exam vitals bp hr rr sao2 general alert oriented no acute distress heent sclera anicteric mmm oropharynx clear left eye contains significant ecchymosis also slight ecchymosis on right eye neck supple jvp not elevated no lad lungs clear to auscultation bilaterally no wheezes rales ronchi cv irregular rate and rhythm normal s1 s2 abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly gu no foley ext warm well perfused pulses no clubbing cyanosis or edema neuro cns2 intact motor function grossly normal labs reviewed please see below discharge physical exam vitals temperature bp hr rr sao2 general alert oriented no acute distress heent sclera anicteric mmm oropharynx clear left eye contains significant ecchymosis also slight ecchymosis on right eye neck supple jvp not elevated no lad lungs clear to auscultation bilaterally no wheezes rales ronchi cv irregular rate and rhythm normal s1 s2 abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly gu no foley ext warm well perfused pulses no clubbing cyanosis or edema neuro cns2 intact motor function grossly normal pertinent results labs on admission 05am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 05am blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 05am blood ptt 05am blood glucose urean creat na k cl hco3 angap 05am blood ctropnt 05am blood calcium phos mg 21am blood lactate na k labs on discharge 35am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 35am blood plt 35am blood glucose urean creat na k cl hco3 angap 35am blood calcium phos mg imaging ct orbit impression comminuted mildly depressed fracture of the left orbital floor fracture with approximately mm inferior displacement of the lateral fracture fragment associated high density material completely opacifying the left maxillary sinus likely reflects blood component mild left preseptal and infraorbital soft tissue swelling no discrete fluid collection identified within the limitations of an unenhanced study ct head w o contrast impression cortical irregularity along the left orbital floor with complete opacification of the partially visualized left maxillary sinus is better assessed on same day facial ct concerning for orbital floor fracture mild asymmetric left infraorbital and periorbital soft tissue swelling no retrobulbar hematoma or fat stranding recommend correlation with physical exam findings no acute intracranial abnormalities brief hospital course year old woman with history of an unknown arrhythmia in the past who presents with multiple syncopal episodes found to have new atrial tachycardia atrial tachycardia patient was found to have atrial tachycardia on ekg unclear if this was new as patient noted prior history of fast and irregular heart rate the patient was evaluated by cardiology who recommend starting metoprolol succinate mg daily with plan for event monitoring and echo as an outpatient plan for patient to follow up with dr cardiology in clinic appointment to be made and patient called with this information in next week event monitor to be mailed to patient s home left orbital floor fracture she was found to have a left orbital floor fracture on ct imaging with evidence of blood component plastic surgery evaluated patient and recommended follow up in their clinic in weeks with number provided syncope patient presented with multiple falls including one with a head strike loss of consciousness unclear cause of syncope though work up showed atrial tachycardia though unclear if this was new orthostatic vital signs noted to be negative tox screen also noted to negative plan for event monitor as above patient counseled about not driving for months pending further work up syncope given possible loss of consciousness with this syncopal episode transamintis patient also noted to have transaminitis prior to transfer to ast and alt on recheck at noted to be alt ast and stable hep c antibody in outpatient records on checked and noted to be low positive with negative subsequent viral load would recommend further work up of this as an outpatient hyponatremia patient with hyponatremia to on admission on recheck noted to be urine sodium noted to be and urine osm showed most consistent with psychogenic polydipsia she noted that she was drinking up to 6l of water daily prior to coming to the hospital prior to leaving the hospital sodium normalized we recommended cutting back on water intake by at least half anxiety continued lorazepam per home regimen transitional issues metoprolol succinate mg daily started chem to be checked at time of follow up appointment with pcp to ensure normalized sodium level sodium on discharge of please recheck lft s on follow up alt ast would recommend further work up of transaminitis as outpatient event monitored ordered and will be sent to patients home echocardiogram to occur as outpatient follow up with dr to be scheduled and patient called with appointment please see plastic surgery concerning left orbital floor fracture should be seen in next weeks medications on admission the preadmission medication list is accurate and complete vitamin b complex cap po daily lorazepam mg po q8h prn anxiety ranitidine mg po bid multivitamins tab po daily discharge medications metoprolol succinate xl mg po daily rx metoprolol succinate mg tablet s by mouth daily disp tablet refills lorazepam mg po q8h prn anxiety multivitamins tab po daily ranitidine mg po bid vitamin b complex cap po daily discharge disposition home discharge diagnosis primary atrial tachycardia syncope hyponatremia left orbital floor fracture discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms you came to the hospital after falling and were found to have a rapid heart rate called atrial tachycardia we started you on a medication called metoprolol to help slow down your heart rate we recommend that you follow up with dr cardiologist you saw in the hospital he will order an echocardiogram for you and an event monitor that will be mailed to your house to monitor your heart rate dr will call you to set up a follow up appointment in one month we also discussed with you that it is not safe to drive as you have had multiple episodes of passing out and until the cause of this is found it is not safe for you to drive for at least a month period you also had lab abnormalities including a low sodium level the levels corrected without intervention you has no seizures or altered mental status despite you low sodium your team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies clozaril tegretol benadryl attending chief complaint dyspnea orthopnea major surgical or invasive procedure none history of present illness y o m with nonischemic dilated cmy ef attributed to an anti psychotic medication mild phtn mr and tr ckd baseline cr with biv icd presents for decreased appetite dyspnea and orthopnea patient had been taking an extra mg of torsemide for a total of mg daily for a couple of weeks at the end of and to given his ongoing orthpnea and pnd which seemed to improve his symptoms however continued to endorse doe his reported dry weight is pounds on his home scale and most recently was about lbs over the last month he continues to complain of orthopnea and pnd he endorses continuing to gain weight and was instructed by dr office to continue taking mg po torsemide daily he confirms that he does take this every day states that he does not weigh himself daily ekg ventricular pacing labs studies notable for cr bun patient was given furosemide mg iv bolus followed by mg hr iv drip on the floor t bp hr rr spo2 on ra wt kg lbs on review of systems he endorses loss of appetite pnd orthopnea palpitations cough vomiting has had increased doe says now can only walk blocks could not easily climb flight of stairs denies chest pain syncope dizziness lightheadedness claudications leg swelling fever hematemesis hematochezia diarrhea constipation changes in urination unintentional weight loss past medical history chronic systolic heart failure and cardiomyopathy dating back to with lvef pacemaker with icd since not biv pacing due to chest wall stimulation paranoid schizophrenia depression hypertension hyperlipidemia renal cancer with tumor extraction in gerd barretts esophagus complete teeth extraction mild anemia social history family history premature coronary artery disease paternal maternal grandfathers had heart dz physical exam admission physical examination vitals t bp hr rr spo2 on ra wt kg lbs general lying in bed nad interactive heent sclerae anicteric perrl ntnc oral mucosae moist pale neck supple cv hrrr jvd not appreciated lungs inspiratory and expiratory wheezes throughout respiration at bases especially on right abdomen soft mildly edematous bs mildly tender to palpation in epigastrium extr warm well perfused no c c radial tibial dp pulses no pitting edema neuro moving all extremities purposefully discharge physical examination vitals on ra wt kg lbs kg kg general lying in bed nad interactive heent sclerae anicteric perrl ntnc oral mucosae moist pale neck supple cv hrrr jvp to earlobe lungs slight wheezes throughout respiration at bases especially on right abdomen soft non distended non tender bs extr warm well perfused no c c radial tibial dp pulses no pitting edema neuro moving all extremities purposefully pertinent results admission labs 00pm glucose urea n creat sodium potassium chloride total co2 anion gap 00pm phosphate magnesium 15pm ctropnt 20pm glucose urea n creat sodium potassium chloride total co2 anion gap 20pm calcium phosphate magnesium 20pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 20pm plt count 20pm ptt discharge labs 28am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 28am blood plt 20pm blood glucose urean creat na k cl hco3 angap 20pm blood mg 28am blood digoxin y o m with nonischemic dilated cmy ef etiology unknown possibly due to antipsychotic medication mild phtn mr and tr ckd creatinine with biv icd presents with intermittent sob he had no crackles on exam and cxr found no overt pulmonary edema however pt has severe heart failure and therefore may not have pulmonary edema or crackles secondary to lymphatic changes the patient was diuresed with iv lasix his breathing improved and he was able to ambulate comfortably he was discharged on po torsemide mg daily and his pre admission medications patient not on acei due to low bp and renal function the use of dobutamine to improve cardiac function was discussed with the patient who decided that he did not feel comfortable administering iv medications at home transitional issues the patient was most recently taking mg torsemide daily but became volume overloaded daily dose may need to be adjusted patient was dced on mg torsemide daily he states that he does not weigh himself regularly it will be useful to help him to do this weight on discharge kg from kg on admission contact patient code full medications on admission the preadmission medication list is accurate and complete omeprazole mg po daily potassium chloride meq po bid spironolactone mg po daily torsemide mg po daily zolpidem tartrate mg po qhs prn insomnia aspirin mg po daily vitamin d unit po daily fish oil omega mg po bid centrum silver multivit min fa lycopen lutein br mv min folic acid lutein mg mcg mcg oral daily allopurinol mg po daily alprazolam mg po bid atorvastatin mg po qpm digoxin mg po daily metoprolol succinate xl mg po daily olanzapine mg po qhs hydralazine mg po q8h isosorbide mononitrate extended release mg po daily discharge medications allopurinol mg po daily alprazolam mg po bid aspirin mg po daily atorvastatin mg po qpm digoxin mg po daily fish oil omega mg po bid hydralazine mg po q8h isosorbide mononitrate extended release mg po daily metoprolol succinate xl mg po daily olanzapine mg po qhs omeprazole mg po daily potassium chloride meq po bid spironolactone mg po daily vitamin d unit po daily zolpidem tartrate mg po qhs prn insomnia centrum silver multivit min fa lycopen lutein br mv min folic acid lutein mg mcg mcg oral daily torsemide mg po daily rx torsemide mg tablet s by mouth daily disp tablet refills rx torsemide mg tablet s by mouth with mg tablet for mg total disp tablet refills discharge disposition home discharge diagnosis primary diagnosis acute on chronic systolic heart failure secondary diagnosis dilated cardiomyopathy discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr thank you for coming to it was a pleasure to care for you you come to the hospital because you were feeling short of breath and had difficulty breathing when lying down we found that you had collected extra fluid in your lungs that was making it hard for you to breathe you received medications lasix intravenously that helped you take off the extra fluid we are changing your home torsemide dose to mg weigh yourself every morning call md if weight goes up more than lbs followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies clozaril tegretol benadryl attending chief complaint shortness of breath major surgical or invasive procedure intubated placed extbuated ganz removed history of present illness mr is a year old man with pmh significant for nonischemic dilated cmp ef attributed to anti psychotic medication with biv icd mild phtn mr and tr ckd baseline cr who presented to osh with progressive transferred to per patient request now transferred to ccu for cardiogenic shock per report patient presented to osh with progressive sob there reportedly evaluated by cardiologist with exam notable for elevated jvp and bilateral crackles osh labs showed hgb wbc bicarb cr mild transaminitis trop negative ntprobnp elevated crackles bilaterally creatinine with small anion gap elevated ntprobnp the patient was subsequently transferred to at patient request upon arrival to at approximately 30pm patient noted to be tachypneic to rr jvp to 14cm bilateral crackles but conversant prior to iv access was able to be obtained patient received 5mg po metolazone and 160mg po torsemide with no urine ouput the patient triggered at 00am for increasing tachypnea for which he was administered 160mg iv lasix x1 without uop the patient subsequently became more tachypneic hypotensive to sbp and hypoxic to then lost pulse ox waveform while noted to be cool and clamped down respiratory code blue was called and patient was intubated and transferred to ccu upon arrival to ccu the patient became hypotensive to sbp for which patient was started dopamine past medical history chronic systolic heart failure and cardiomyopathy dating back to with lvef pacemaker with icd since not biv pacing due to chest wall stimulation paranoid schizophrenia depression hypertension hyperlipidemia renal cancer with tumor extraction in gerd barretts esophagus complete teeth extraction mild anemia social history family history premature coronary artery disease paternal maternal grandfathers had heart dz physical exam admission exam vs 90v paced intubated weight 3kg tele v paced junctional gen intubated sedated heent pupils pinpoint but reactive neck supple jvd to 13cm cv faint heart sounds rrr no m r g lungs faint crackles bilaterally otherwise coarse abd soft nt nd ext lue cool neuro unable to assess as intubated sedated discharge exam vs 100s 70s 100ra 3kg a sensed v paced gen a o3x nad pleasant appropriate heent anicteric sclera eom grossly intact neck supple jvd at base of clavicle at 30deg cv rrr s1 s2 with systolic murmur lungs ctab rul rml regions with expiratory wheeze more pronounced over r middle aspect abd soft nt nd ext improved lue still edematous warm well perfused no longer dusky in color pulses mildly purpuric to erythematous neuro aox3 pertinent results admission labs 03am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 03am blood ptt 03am blood glucose urean creat na k cl hco3 angap 03am blood alt ast alkphos totbili 03am blood ck mb ctropnt 03am blood albumin calcium phos mg 06am blood temp po2 pco2 ph caltco2 base xs intubat intubated 12am blood lactate 54am blood hgb calchct o2 sat 06am blood freeca pertient labs lactate 50pm 04am 31am 29pm 41am 14am 54pm 51am 51am 11pm 01pm 16am 54am 06am 12am blood gases 29pm mix po2 pco2 ph caltco2 base xs 43pm po2 pco2 ph caltco2 base xs 06pm mix po2 pco2 ph caltco2 base xs 45pm mix po2 pco2 ph caltco2 base xs 41am mix po2 pco2 ph caltco2 base xs 14am mix po2 pco2 ph caltco2 base xs 54pm art po2 pco2 ph caltco2 base xs 51am art po2 pco2 ph caltco2 base xs 01pm mix po2 pco2 ph caltco2 base xs 11pm mix po2 pco2 ph caltco2 base xs 16am mix po2 pco2 ph caltco2 base xs 54am mix po2 pco2 ph caltco2 base xs 06am po2 pco2 ph caltco2 base xs swan numbers trend swan numbers q4h goal wedge of pap pcwp cvp mvo2 co ci mean mean 11am cvp pap mvo2 started on lasix gtt pcwb18 cvp6 pap74 co3 ci2 increased lasix gtt svr down pa down cvp discsharge labs 35am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 35am blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 35am blood plt 35am blood glucose urean creat na k cl hco3 angap 35am blood alt ast ld ldh ck cpk alkphos totbili 11pm blood ck mb mb indx ctropnt 35am blood albumin calcium phos mg 29pm blood type mix po2 pco2 ph caltco2 base xs 20am blood lactate cardiac ekg normal sinus rhythm ventricular pacing left atrial abnormality compared to the previous tracing of patient is now fully paced biv icd interrogation v pacing less than longest ventricular sensing episode since the last session is greater than seconds ventricular sensing episodes averaged hr day since the last session tte left ventricular wall thicknesses are normal the left ventricular cavity is dilated overall left ventricular systolic function is severely depressed lvef secondary to global contractile dysfunction and marked mechanical dyssynchrony the right ventricular free wall thickness is normal the right ventricular cavity is dilated with moderate global free wall hypokinesis the aortic valve leaflets are mildly thickened but aortic stenosis is not present the mitral valve leaflets are mildly thickened moderate to severe mitral regurgitation is seen moderate tricuspid regurgitation is seen there is no pericardial effusion compared with the prior study images reviewed of the findings are similar ecg atrial sensed ventricular paced rhythm compared to tracing there has been a change in the qrs morphology and duration and a probable premature ventricular beat with a slower sinus rate the prior tracing being beats per minute clinical correlation is suggested as before imaging ruq us patent hepatic vasculature trace ascites cholelithiasis without evidence of cholecystitis l ue doppler extensive acute deep vein thrombosis noted within the left subclavian vein left axillary vein and extending into both left brachial veins and left basilic vein as detailed above nonocclusive thrombus at the distal left cephalic vein as above xr for line placement fluoroscopic images show placement of a catheter that extends into the left pulmonary artery further information can be gathered from the operative report brief hospital course with nonischemic dilated cmp ef with biv icd mild phtn mr and tr ckd baseline cr who presented to osh with progressive transferred to per patient request now transferred to ccu for cardiogenic shock coronaries unknown pump ef rhythm v paced cardiogenic shock acute decompensated systolic heart failure nonischemic cmp with ef presenting with progressive sob trop negative not responsive to high dose diuretics s p 1000mg iv diuril and 200mg iv lasix he was started on dobutamine levophed to maintain map he received mg chlorothiazide and mg iv lasix swan was placed in the lij upon arrival to the ccu patient was intubated sedated right heart catheter was placed and doubatmine titrated with lasix gtt to remove fluid and optimize volume status cvp downtrended from s to dobutamine was weaned and final swan numbers after dobutamine were in ccu at s p discontinuation of dobutamine cvp pap co ci svr mvo2 the swan was removed and lasix drip titrated so patient remained net even upon discontinuation of dobuatmine lasix gtt patient remained warm well perfused with flat jvd he was started on isordil mg tid hydralazine mg bid digoxin 125mg once hemodynamically stable patient was restarted on metoprolol xl mg daily in discussion with dr was decided to hold sprinolactone additionally his diuretic regimen was optimized and patient was discharged on mg torsemide daily for a goal to stay evolumeic hypoxic resp failure likely in the setting of volume overload and cardiogenic shock found to have resp and metabolic acidosis on admission emergently intubated upon arrival to the micu on with improvement of his cardiogenic shock he was extubated on and maintained appropriated spo2 on ra left arm dvts patient was acidotic sodium bicarbonate was infused after the infusion the through iv in the left arm the limb became cool pale painful but radial brachial pulses remained in tact l ue dopplers demonstrated left subclavian vein left axillary vein and extending into both left brachial veins and left basilic vein he was maintained on a heparin gtt with ptts that were therapeutic in the range of he was bridged to warfarin first at 2mg then uptitrated to mg maintaining therapeutic inr between dr patient s pcp follow inr in the outpatient setting acute on chronic kidney disease on admission cr from baseline baseline cr etiology likely cardiorenal he received cholrothiazide spironolactone to augment diurese on arrival and was transitioned to lasix gtt dobutamine as above with improvement in cr to coagulopathy on admission inr with normal ptt likely in the setting of shock liver from cardiogenic shock inr improved to with resolution of cardiogenic shock chronic issues hld continue atorvastatin 10mg qhs hyperlipidemia continue atorvastatin 10mg qhs history of schizophrenia stable continue home zyprexa 10mg qhs started and alprazolam 5mg tid transitional issues continued home cardiac medications on discharge metoprolol xl mg daily digoxin mg daily hydralazine mg tid imdur mg daily decreased toresimide to mg daily discontinued sprinolactone per dr chem10 check two days after discharge on check dig level if changing renal function dr to follow inr with next inr check on follow up with dr congestive heart failure appointment scheduled at nephrology discharge weight 3kg full code confirmed his contact is his father his contact is his girlfriend on admission the preadmission medication list may be inaccurate and requires futher investigation allopurinol mg po daily alprazolam mg po bid aspirin mg po daily atorvastatin mg po qpm digoxin mg po daily fish oil omega mg po bid hydralazine mg po q8h isosorbide mononitrate extended release mg po daily metoprolol succinate xl mg po daily olanzapine mg po qhs omeprazole mg po daily potassium chloride meq po bid spironolactone mg po daily vitamin d unit po daily zolpidem tartrate mg po qhs prn insomnia centrum silver multivit min fa lycopen lutein br mv min folic acid lutein mg mcg mcg oral daily torsemide mg po bid discharge medications allopurinol mg po daily aspirin mg po daily atorvastatin mg po qpm digoxin mg po daily hydralazine mg po q8h isosorbide mononitrate extended release mg po daily metoprolol succinate xl mg po daily olanzapine mg po qhs potassium chloride meq po daily rx potassium chloride klor con meq tablet s by mouth once a day disp tablet refills vitamin d unit po daily zolpidem tartrate mg po qhs prn insomnia warfarin mg po daily16 rx warfarin coumadin mg tablet s by mouth once a day disp tablet refills centrum silver multivit min fa lycopen lutein br mv min folic acid lutein mg mcg mcg oral daily omeprazole mg po daily torsemide mg po daily rx torsemide mg tablet s by mouth once a day disp tablet refills outpatient lab work icd i50 schf chem na k cl hco3 bun cr gluc mag calc phos fish oil omega mg po bid alprazolam mg po tid prn anxiety discharge disposition home discharge diagnosis primary systolic congestive heart failure acute on chronic kidney injury schizophrenia 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 with congestive heart failure upon arrival you were having difficulty breathing and were cold clammy a breathing tube was placed and your breathing assisted a line was placed to measure the pressures around your heart and a medication called dobutamine was used to help with your heart failure extra fluid was removed using a medication called furoseimide the breathing tube was removed the dobutamine was stopped and your heart failure was controlled you should take the following medications to help with the functioning of your heart imdur isosorbide dinitrated mg every day hydralazine mg three times a day metoprolol succinate xl mg daily digoxin mg daily it is important to take these medications as prescribed if you feel lightheaded dizzy call your doctor additionally you will take a medication to help remove extra fluid from your body called torsemide mg daily you should weight yourself daily your weight when you left the hospital was lbs kg if you gain or lose three pounds you should call your doctor while you were in the hospital you were found to have blood clots in the veins in your left arm we started a medication to prevent further blood clots called warfarin mg daily you will need to get weekly blood draws to ensure the medication is at the right level dr will follow your inr warfarin prevents your blood from clotting too easily if you fall hit your head or have a car accident you should report to the emergency room thank you for allowing us to participate in your care care team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies clozaril tegretol benadryl attending chief complaint chest pain major surgical or invasive procedure none history of present illness mr is a year old m with pmh nicm ef s p biv icd with upgrade to crt d by surgical epicardial lead placement recently interrogated and functioning appropriately mr and tr htn hld and paranoid schizophrenia who presents with complaints of chest pain reportedly he was seen at his pcp s office today with complaints of chest pain since 9pm yesterday was found to be tachypneic hypotensive to systolic and tachycardic to 130s he was sent to an osh and received morphine with partial resolution of his pain also received 5mg iv metoprolol for tachycardia he was then transferred to the ed in the ed initial vitals were t hr bp rr o2 sat nc ekg v paced rhythm rate no ischemic changes labs studies notable for trop bnp na k hemolyzed cl bicarb bun cr wbc hgb plt ptt inr cardiology consulted recommended admission for chf exacerbation he briefly became hypotensive to the again but his bp subsequently normalized to the 100s his baseline without intervention did not receive any medications on arrival to the ccu feeling well denies dyspnea orthopnea ongoing chest pain nausea vomiting diarrhea reports chest pain was a earlier today states he has been compliant with meds denies dietary indiscretion of note pt is seen weekly in the clinic where he receives iv lasix 120mg he was also recently started on metolazone his hydralazine and imdur doses were recently decreased after a hospitalization for chf exacerbation during which was complicated by symptomatic hypotension he has been in discussion with the clinic heart failure team about possible advanced therapies but is felt not to be a candidate for these due to psychosocial factors as well as patient hesitation he has begun to discuss the possibility of hospice but this process has not formally begun past medical history chronic systolic heart failure and cardiomyopathy dating back to with lvef as low as pacemaker with icd no longer biv pacing due to chest wall stimulation now upgraded to crt by surgical epicardial lead placement paranoid schizophrenia depression hypertension hyperlipidemia renal cancer with tumor extraction in gerd barretts esophagus complete teeth extraction mild anemia history of dvt social history family history premature coronary artery disease paternal maternal grandfathers had heart dz physical exam admission physical exam vs t afeb bp hr rr o2 sat ra general ill appearing disheveled in no acute distress alert oriented x3 heent normocephalic atraumatic sclera anicteric perrl eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthelasma neck supple jvp of cm cardiac pmi located in intercostal space midclavicular line regular rate and rhythm normal s1 s2 iii vi holosystolic murmur no heave lungs no chest wall deformities or tenderness slightly increased work of breathing trace crackles at l base abdomen soft non tender non distended no hepatomegaly no splenomegaly extremities warm well perfused pitting edema b l skin no significant skin lesions or rashes pulses distal pulses palpable and symmetric discharge physical exam expired pertinent results admission labs 30pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30pm blood neuts lymphs monos eos baso nrbc im absneut abslymp absmono abseos absbaso 30pm blood ptt 30pm blood glucose urean creat na k cl hco3 angap 37pm blood alt ast alkphos totbili 30pm blood 37pm blood calcium phos mg 37pm blood digoxin 45pm blood lactate important labs 22pm blood po2 pco2 ph caltco2 base xs 20am blood digoxin 30pm blood ctropnt 37pm blood ck mb ctropnt 04am blood ck mb ctropnt final labs 25pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 25pm blood ptt 25pm blood glucose urean creat na k cl hco3 angap 03am blood alt ast ld ldh alkphos totbili 25pm blood calcium phos mg 49pm blood lactate micro labs urine culture no growth important imaging studies cxr compared to chest radiographs through there is no pulmonary edema pleural effusions are small if any no pneumothorax severe cardiomegaly is chronic combination of trans vascular and epicardial pacing an defibrillator device is unchanged no pneumothorax unilateral upper extremity us occlusive left distal cephalic vein thrombus remaining left upper extremity veins are patent without evidence of thrombus cxr pullback of right picc is recommended by cm for termination at the cavoatrial junction cxr right picc line terminates in lower svc brief hospital course yo m with past medical history of non ischemic cardiomyopathy ef s p biv icd with upgrade to crt d recently interrogated and functioning appropriately htn hld and paranoid schizophrenia who presented with chest pain found to have volume overload consistent with chf exacerbation he unfortunately passed away on death acute on chronic systolic chf decompensated on admission patient was volume overloaded and hypotensive he was admitted to the ccu where he was diuresed with lasix iv and continued on his home hydralazine and imdur for afterload reduction throughout his ccu course he became more hypotensive and was started on dobutamine drip with initial improvement in his blood pressure he subsequently became more hypotensive while on dobutamine drip requiring levophed gtt and midodrine to maintain map we attempted multiple times to wean him off his infusions with no success given hypotension he was eventually transitioned to a dopamine drip with the goal keeping him on one drip to be discharged on however he expired on goc throughout his hospital stay there was discussion with him regarding his goals of care in context of his end stage heart failure eventually he decided to transition to comfort measures prior to expiring chest pain likely was demand ischemia in setting of chf exacerbation he had no ischemic changes on ecg and his trop mb remained flat from admission acute on chronic kidney disease likely prerenal in setting of chf exacerbation his serum creatinine was followed for improvement a digoxin level was checked and was supratherapeutic so his digoxin was held and then eventually discontinued coagulopathy inr was on admission patient seemed unsure of his coumadin regimen and states that he has had supratherapeutic inr before his coumadin was held and eventually discontinued chronic issues paranoid schizophrenia depression anxiety he was continued on his home olanzapine and alprazolam hld he was continued on his home statin but this was discontinued upon discharge esophagus he was originally continued on his home omeprazole insomnia his ambien was held originally but it was restarted to improve his sleep medications on admission the preadmission medication list is accurate and complete allopurinol mg po daily aspirin mg po daily atorvastatin mg po qpm digoxin mg po daily hydralazine mg po bid isosorbide mononitrate extended release mg po qhs metoprolol succinate xl mg po daily olanzapine mg po qhs potassium chloride meq po 6x week vitamin d unit po daily zolpidem tartrate mg po qhs prn insomnia warfarin mg po daily16 centrum silver multivit min fa lycopen lutein br mv min folic acid lutein mg mcg mcg oral daily omeprazole mg po daily torsemide mg po daily fish oil omega mg po bid alprazolam mg po tid prn anxiety metolazone mg po 1x week we potassium chloride meq po 1x week we discharge medications expired discharge disposition expired discharge diagnosis primary diagnoses death decompensated systolic heart failure hypotension goals of care discussions acute kidney injury with chronic kidney disease secondary diagnoses paranoid schizophrenia depression anxiety discharge condition expired discharge instructions expired followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies percocet attending chief complaint palpitations major surgical or invasive procedure none history of present illness with hx sibo panic attacks presents with palpitations and concern for vt from osh patient was at home when he developed palpitations ems was called and reportedly found patient in vtach he was brought to and started on amiodarone strips from show run of nsvt patient reports he has been taking herbal supplements for weeks at recommendation of homeopathic doc due to brain fog in the ed initial vs were ra labs showed cbc chem10 trop tsh and bnp all wnl patient received po acetaminophen mg iv amiodarone ep was consulted transfer vs were ra on arrival to the floor patient reports he has had episodes of palpitations dating back over last several years but none this severe he is currently feeling much improved he started taking otc supplements this last due to perceived mental slowing he also changed his diet and went gluten free no acute complaints currently past medical history small intestine bacterial overgrowth sibo anxiety kidney stones hernia social history family history father with mi in his mother died of lung ca smoker physical exam admission physical exam vs ra general adult male in nad heent at nc eomi perrl anicteric sclera pink conjunctiva mmm neck supple no lad no jvd heart rrr s1 s2 no murmurs gallops or rubs lungs ctab no wheezes rales rhonchi breathing comfortably without use of accessory muscles abdomen nondistended nontender in all quadrants no rebound guarding no hepatosplenomegaly extremities no cyanosis clubbing or edema pulses dp pulses bilaterally neuro a ox3 moving all extremities with purpose skin warm and well perfused no excoriations or lesions no rashes discharge physical exam vitals po bp hr rr ra tele no alarms general well appearing gentleman in nad oriented x3 mood affect appropriate heent ncat sclera anicteric perrl eomi neck supple with no jvp discernible at degrees cardiac rrr normal s1 s2 no m r g no thrills lifts no s3 or s4 lungs ctab abdomen soft ntnd no hsm or tenderness extremities no c c e skin no visible lesions pertinent results labs on admission 18pm urine blood neg nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg 18pm urine color straw appear hazy sp 18pm urine uhold hold 18pm urine hours random 21pm ptt 21pm plt count 21pm neuts monos eos basos im absneut abslymp absmono abseos absbaso 21pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 21pm t3 21pm tsh 21pm calcium phosphate magnesium 21pm probnp 21pm ctropnt 21pm estgfr using this 21pm glucose urea n creat sodium potassium chloride total co2 anion gap labs on discharge 55am blood glucose urean creat na k cl hco3 angap 55am blood alt ast alkphos totbili 55am blood ck mb ctropnt 55am blood calcium phos mg pertinent images echompression normal study normal biventricular cavity sizes with preserved regional and global biventricular systolic function no structural heart disease or pathologic flow identified clinical implications based on aha endocarditis prophylaxis recommendations the echo findings indicate prophylaxis is not recommended clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data stress test impression good functional capacity no anginal symptoms or ischemic ekg changes rare isolated vpbs appropriate hemodynamic response to exercise brief hospital course with hx sibo panic attacks presents with palpitations and concern for vt from osh palpitations nsvt patient presented to and was found to have nsvt transferred to for further evaluation review of strips from ems and showed nsvt troponins here were negative and he had no nsvt on telemetry while admitted he remained hemodynamically stable with no chest pain or subjective palpitations he had an echo and an exercise stress test both of which were normal tsh was normal he was started on metoprolol and advised to refrain from taking non fda approved supplements as he was on an extensive regimen of supplements on admission pt was discharged with a cardiac monitor close ep followup and the plan for outpatient cardiac mri for further workup transitional issues per ep team pt should have cardiac mri for further workup of his nsvt ordered in omr please follow up results of cardiac monitor medications on admission the preadmission medication list is accurate and complete in fla mend turmeric herbal complex mg oral daily dhea prasterone dhea br prasterone dhea calcium carb mg mg calcium oral daily iodine kelp mg oral daily tyrosine mg oral daily discharge medications metoprolol succinate xl mg po daily rx metoprolol succinate mg tablet s by mouth once a day disp tablet refills discharge disposition home discharge diagnosis primary diagnosis non sustained ventricular tachycardia secondary diagnoses small intestine bacterial overgrowth 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 did you come to the hospital your heart was beating very fast and you were not feeling well because of this what happened while you were here we did several tests to make sure you were not having a dangerous heart rhythm or lack of blood flow to the heart all the tests were normal we started you on a medicine to try and keep you from having this abnormal rhythm again what should you do when you leave the hospital please continue to take all of your medications as directed and follow up with all of your doctors we made an appointment for you with dr you likely have a cardiac mri in the near future for further evaluation as we discussed please stop taking all the of over the counter supplements you were taking as these may have contributed to your fast heart beat again it was a pleasure taking care of you sincerely your team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies statins hmg coa reductase inhibitors penicillins attending chief complaint diarrhea major surgical or invasive procedure fecal transplant with dr on history of present illness with history most notable for dementia and recurrent clostridium difficile currently on oral vancomycin who presents with one week of diarrhea and abdominal pain after stopping po vancomycin the patient has tested positive for c diff multiple times and has been on off po vancomycin since the patient saw dr for discussion of fecal transplant on her daughter stopped vancomycin on that day to retest her stool per dr and she was positive for c diff antigen after she stopped the medication she had worsening diarrhea her daughter restarted vancomycin on her abdominal pain is intermittent cramping diffuse and nonradiating per daughter patient is unable to describe her abdominal pain nothing makes it better or worse her stools have been loose watery at least bm per day per daughter she has not had any bloody stools or dark stools the patient also has fecal incontinence the patient has no chest pain sob fever sweats malaise fatigue nausea vomiting no recent travel history or exposure to sick contacts or unclean water past medical history dementia recurrent c diff infections poor hearing diabetes mellitus was initialyl on metformin but has not been on metformin for the last months hyperlipidemia social history family history non contributory physical exam admission physical exam vs afebrile hr bp 110s 50s rr o2 ra gen sitting on commode in no acute distress cooperative throughout exam heent perrl dry mucous membranes no pharyngeal exudate cv regular rate and rhythm normal s1 and s2 no murmurs resp ctab with no crackles or wheezing abdom nondistended soft nontender to palpation in all four quadrants hyperactive bowel sounds no guarding or rebound tenderness extremities no cyanosis edema skin no rashes neuro cn intact sensation intact in upper and lower extremities moving bilateral extremities spontaneously discharge physical exam hr data last updated temp tm bp hr rr o2 sat o2 delivery ra wt lb kg gen sitting in bed in no acute distress heent dry mucous membranes cv regular rate and rhythm normal s1 and s2 no murmurs resp ctab with no crackles or wheezing abdom nondistended soft nontender to palpation in all four quadrants normoactive bowel sounds no guarding or rebound tenderness extremities no cyanosis edema skin no rashes neuro moving bilateral extremities spontaneously pertinent results admission labs 20am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 20am blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 20am blood glucose urean creat na k cl hco3 angap 20am blood calcium phos mg pertinent reports ct abdomen and pelvis w contrast marked colonic wall thickening and mucosal enhancement extending from the splenic flexure distally to the rectum is consistent with proctocolitis in keeping with patient s history of c diff colitis trace pelvic free fluid is likely secondary to colitis no free air or abscess cm left adrenal nodule can be further characterized with adrenal ct or mr in non emergent outpatient basis cm right adnexal simple cyst for asymptomatic incidental simple cysts thin walled no enhancement water intensity density round or oval less than cm follow up is not required discharge labs 04am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 20am blood glucose urean creat na k cl hco3 angap 20am blood albumin calcium phos mg with history notable for dementia and recurrent clostridium difficile infection currently on oral vancomycin who presents with one week of diarrhea and abdominal pain secondary to nonsevere c diff colitis currently the patient has no abdominal pain on exam with stable vital signs and in no acute distress will be going for fecal transplant on acute issues c diff colitis diarrhea abdominal pain patient has had recurrent c diff infections and is on oral vancomycin at she recently tested positive for c diff toxin within the last days she has no other signs of an infection elsewhere clear lungs negative ua no uri symptoms no abscess seen on ct her ct abdomen pelvis showed colitis with no perforation or megacolon it is reassuring that her abdomen was soft nontender nondistended with normoactive bowel sounds throughout this hospitalization she was initially treated with po vancomycin 125mg qid she underwent fecal transplant with dr on without complication chronic issues history of type ii diabetes mellitus per daughter patient was on metformin but she was taken off five months ago as her blood glucose has been stable her blood glucoses were stable during this hospital course continued lisinopril 5mg daily per daughter patient was put on lisinopril for renal protective effect never had high blood pressure depression continued fluoxetine 10mg daily dementia continued donepezil 20mg daily continued memantine 5mg daily transitional issues cm left adrenal nodule can be further characterized with adrenal ct or mr as outpatient can continue to follow up with dr her recurrent c diff following fecal transplant to ensure resolution of symptoms code status full emergency contact daughter hcp medications on admission the preadmission medication list may be inaccurate and requires futher investigation donepezil mg po qhs fluoxetine mg po daily haloperidol mg po bid lisinopril mg po daily memantine mg po daily vancomycin oral liquid mg po q6h metronidazole mg iv q8h discharge medications donepezil mg po qhs fluoxetine mg po daily haloperidol mg po bid lisinopril mg po daily memantine mg po daily discharge disposition with service facility discharge diagnosis primary diagnosis c diff colitis secondary diagnoses type ii diabetes mellitus dementia depression discharge condition mental status confused sometimes level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear ms what brought you to the hospital you came in with more than one week of diarrhea and abdominal pain what did we do for you in the hospital we gave you iv fluids you had a ct scan which showed some inflammation around your colon we reached out to your outpatient gi doctor who arranged for you to get a fecal transplant on what should you do after leaving the hospital you should follow up with your gi doctor you should follow up with your primary care provider sincerely your team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies morphine bactrim feldene celebrex naprosyn attending chief complaint abdominal pain major surgical or invasive procedure uncomplicated ercp history of present illness h o sleeve gastrectomy with 5d of mailaise llq abdominal pain evolving generalized abdominal pain and fevers and chills now diagnosed with acute pancreatitis and diverticulitis she describes progressively worse now severe abdominal pain specifically ruq and epigastric radiating to back and shoulders and llq pain she was seen in urgent care this weekend w urine sent and cipro prescribed she came to today where she had hypotension and imaging ct abdomen and labs showed acute pancreatitis and diverticulitis and cholestasis she received ivf and ertapenem she came to and ercp was performed w sphincterotomy and balloon extraction of stones ros fever chills mailaise vomit x1 last week reduced oral intake some dysuria and frequency no other change in health in 13pt ros unless described above past medical history osa on bipap nash s p sleeve gastrectomy at arthritis s p hysterectomy for endometrial hyperplasia panniculectomy her gallbladder remains after above surgeries social history family history mother w colon ca physical exam ra aox3 attentive and not confused some scleral icterus tongue dry neck supple face symmetric clear bs regular s1 and s2 obese abdomen bowel sounds present ruq and epigastric tenderness to palpation less intense tenderness in llq unable to appreciate if hepatomegaly present no peripheral edema or rash did not test gait speech fluent mood calm able to sit up on her own pertinent results ercp evidence of a sleeve gastrectomy was noted the major papilla was on the rim of a large diverticulum cannulation of the biliary duct was successful and deep with a sphincterotome using a free hand technique there was a filling defect that appeared like sludge in the lower third of the common bile duct there was mild upstream dilation with the cbd measuring 8mm in maximal diameter a sphincterotomy was performed in the o clock position using a sphincterotome over an existing guidewire minor oozing was noted balloon sweeps were performed of the common bile duct which yielded sludge but no obvious stone further sweeps were performed until no debris was noted completion occlusion cholangiogram revealed no further filling defects 10cc epinephrine were injected for hemostasis successfully at the major papilla 50am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 50am blood neuts bands lymphs monos eos baso myelos absneut abslymp absmono abseos absbaso 50am blood glucose urean creat na k cl hco3 angap 50am blood alt ast alkphos totbili 50am blood lipase 50am blood albumin calcium phos mg 52am blood lactate ct impression fat stranding around pancreas and second and third portions duodenum possibly pancreatitis possibly duodenitis clinical correlation advised acute mild uncomplicated sigmoid diverticulitis gallstones distended gallbladder possibly reflecting fasting state clinical correlation necessary hida scan may be considered for further evaluation if there is right upper quadrant pain hysterectomy other incidental findings as outlined brief hospital course w nash and s p sleeve gastrectomy now hospitalized w gallstone pancreatitis and acute diverticulitis she is now s p ercp and sphincterotomy for associated choledocolithiasis with obstruction she has features of early sepsis including hypotension as low as responsive to fluids at and subjective fevers chills lactate was acute bile duct obstruction with possible early cholangitis due to choledocholithiasis she was managed with fluid resuscitation and ercp with stone extraction biliary jaundice improved and she tolerated a full diet she was instructed to f u with outpatient surgeon for ccy and will do so through pcp she will complete 10day antibiotic course with cipro flagyl acute diverticulitis clinically resolved she will complete days cipro flagyl nash cirrhosis followed by liver clinic in past at and now by local area hepatologist this was clinically stable here osa continued cpap anxiety diazepam prn possible uti i called her pcp s office to inquire about ua and if urine culture results are known sent this past i spoke with rn to review results was given cipro for uti ucx multiple organisms present contaminated specimen medications on admission the preadmission medication list is accurate and complete diphenhydramine mg po qhs prn insomnia diazepam mg po daily prn anxiety ranitidine mg po daily discharge medications diazepam mg po daily prn anxiety ciprofloxacin hcl mg po q12h rx ciprofloxacin hcl mg tablet s by mouth q12 hr disp tablet refills metronidazole mg po q8h rx metronidazole mg tablet s by mouth three times a day disp tablet refills ranitidine mg po daily diphenhydramine mg po qhs prn insomnia discharge disposition home discharge diagnosis choledocholithiasis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted with biliary duct obstruction due to retained gallstones you underwent successful ercp with stone removal with significant clinical improvement you had you tolerated a regular diet without pain you jaundice should continue to improve you understand the recommendation to follow up with a surgeon via pcp for gallbladder removal your outside hospital also had suggestion of acute diverticulitis therefore you should complete a 10day course of antibiotics for this as prescribed followup instructions

name unit no admission date discharge date date of birth sex f service neurology allergies penicillins sulfa sulfonamide antibiotics attending chief complaint headache major surgical or invasive procedure none history of present illness the patient is a year old woman with igg deficiency and recently diagnosed pe on apixaban who presents as a transfer from out of concern for rcvs the patient states that she was in her usual state of health prior to this past at that time she developed acute onset shortness of breath as well as excruciating pain under her right breast in the lateral aspect of her right shoulder she presented to the emergency room at where a d dimer was positive cta revealed pe she was started on lovenox as a bridge to apixaban she has been on apixaban mg bid since the patient was discharged from on she states that she has had mild pain in the right chest since that time but no recurrent episodes of dyspnea she has been taking her apixaban without any missed doses yesterday evening the patient was watching a movie on the couch when she developed a sudden onset left sided frontal headache she states that this was located just above her left eye she states that the pain was excruciating to the point that she could not get off the couch she describes the pain as sharp throbbing pain she notes that when she put her hand on her head she could feel the throbbing the pain seemed to worsen over the course of approximately minutes she notes that it was a first limited to the area above her left eye but subsequently spread to involve the entire forehead she states that she was sensitive to light during this time and had trouble opening her eyes however she denies any vision loss scintillating lights fortifications or diplopia given her recently diagnosed pe the patient was brought to via ems there she received morphine which helped with her pain she also underwent ct and cta of the head and neck this revealed mild narrowing of the proximal and mid and severe narrowing of the distal bilateral posterior cerebral arteries left greater than right no aneurysm given these findings the patient s case was discussed with the vascular fellow at who recommended transfer for further evaluation on neurological ros the patient denies any significant headache history she notes that she may be had one migraine approximately months ago but does not routinely get headaches she denies dysarthria dysphagia lightheadedness vertigo tinnitus or hearing difficulty denies difficulties producing or comprehending speech denies focal weakness numbness parasthesiae no bowel or bladder incontinence or retention denies difficulty with gait on general review of systems the patient denies recent fever or chills no night sweats or recent weight loss or gain denies cough endorses shortness of breath as noted above denies palpitations denies nausea vomiting diarrhea constipation or abdominal pain no recent change in bowel or bladder habits no dysuria denies arthralgias or myalgias denies rash past medical history igg deficiency diagnosed approximately month ago she received a single treatment of ivig at this time she has received no treatment since suspected pots in the setting of recurrent episodes of syncope for years worse over the past year followed by cardiologist dr on in had sbp for a week straight admitted to and concerned for pots subsequently referred to the autonomic neurology division here at for further work up and evaluation she is scheduled for autonomic testing on social history family history parents both alive and healthy mother has mild asthma older brother is healthy grandfather had mi in his no family or personal history of miscarriage physical exam day of admission physical examination vitals t hr bp rr sa ra general sleepy cooperative nad heent nc at no scleral icterus noted mmm no lesions noted in oropharynx there is mild tenderness to palpation of the frontalis muscle bilaterally neck supple no carotid bruits appreciated no nuchal rigidity pulmonary normal work of breathing cardiac rrr warm well perfused abdomen soft non distended extremities no edema skin no rashes or lesions noted neurologic exam mental status alert oriented x able to relate history without difficulty attentive able to name backward without difficulty language is fluent with intact repetition and comprehension normal prosody there were no paraphasic errors cranial nerves ii iii iv vi perrl to 2mm and brisk eomi without nystagmus normal saccades vff to confrontation fundoscopic exam revealed no papilledema exudates or hemorrhages v facial sensation intact to light touch vii no facial droop facial musculature symmetric viii hearing intact to finger rub bilaterally ix x palate elevates symmetrically xi strength in trapezii bilaterally xii tongue protrudes in midline with good excursions strength full with tongue in cheek testing motor normal bulk tone throughout no pronator drift bilaterally no adventitious movements such as tremor noted no asterixis noted delt bic tri wre fe ip quad ham ta l r sensory no deficits to light touch pinprick cold sensation vibratory sense proprioception throughout no extinction to dss no astereognosis in either hand dtrs adductors bilaterally bi tri pat ach l r plantar response was flexor bilaterally coordination no intention tremor normal finger tap bilaterally no dysmetria on fnf or hks bilaterally gait station deferred day of discharge vitals t hr bp rr sa ra general sleepy cooperative nad heent nc at no scleral icterus noted mmm no lesions noted in oropharynx no tenderness to palpation of the frontalis muscle bilaterally neck supple no carotid bruits appreciated no nuchal rigidity pulmonary normal work of breathing cardiac rrr warm well perfused abdomen soft non distended extremities no edema skin no rashes or lesions noted neurologic exam mental status alert oriented x able to relate history without difficulty attentive able to name backward without difficulty language is fluent with intact repetition and comprehension normal prosody there were no paraphasic errors cranial nerves ii iii iv vi perrl to 2mm and brisk eomi without nystagmus normal saccades vff to confrontation fundoscopic exam revealed no papilledema exudates or hemorrhages v facial sensation intact to light touch vii no facial droop facial musculature symmetric viii hearing intact to finger rub bilaterally ix x palate elevates symmetrically xi strength in trapezii bilaterally xii tongue protrudes in midline with good excursions strength full with tongue in cheek testing motor normal bulk tone throughout no pronator drift bilaterally no adventitious movements such as tremor noted no asterixis noted delt bic tri wre fe ip quad ham ta l r sensory no deficits to light touch pinprick cold sensation vibratory sense proprioception throughout no extinction to dss no astereognosis in either hand dtrs adductors bilaterally bi tri pat ach l r plantar response was flexor bilaterally coordination no intention tremor normal finger tap bilaterally no dysmetria on fnf or hks bilaterally gait station deferred pertinent results 21am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 21am blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 21am blood ptt 21am blood glucose urean creat na k cl hco3 angap 21am blood ctropnt brief hospital course is a year old with history of igg deficiency on ivig pe on apixaban likely provoked given on ocp and pe who presented with initial dull headache that rapidly progressed to severe unilateral headache with photophobia phonophobia and nausea on evaluation at an outside hospital she had imaging which showed normal cth and possible vasoconstriction of her pcas and was thus transferred to at her neurologic exam was normal she was treated with toradol compazine and fluids and began to improve initially her apixaban was held she had mri brain with venous and arterial imaging which showed no evidence of rcvs venous thrombus sah or any other abnormality she responded well to analgesics and hydration based on her presentation we initially considered rcvs as potential diagnosis although not true thunderclap headache and ultimately migraine was likely diagnosis we started verapamil to help with prophylaxis against migraines we initially entertained stopping celexa given can be associated with rcvs but ultimately did not given lower suspicion for rcvs psychiatry consult was done as well and their team recommended to continue with celexa and ask pcp for outpatient psychiatry referral abixaban celexa were restarted and patient was discharged on verapamil mg er daily medications on admission the preadmission medication list is accurate and complete citalopram mg po daily apixaban mg po bid discharge medications diphenhydramine mg po q6h prn migraine take with compazine do not drive after taking naproxen mg po q12h prn pain moderate duration days mg bid prn for headache maximum days rx naproxen ec naprosyn mg tablet s by mouth q12 prn disp tablet refills prochlorperazine mg po q8h prn nausea vomiting first line duration days mg q8 prn for nausea maximum duration days rx prochlorperazine maleate compazine mg tablet s by mouth q8 prn disp tablet refills verapamil sr mg po q24h rx verapamil calan sr mg tablet s by mouth once a day disp tablet refills apixaban mg po bid citalopram mg po daily discharge disposition home discharge diagnosis migraine with visual aura discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms you were hospitalized due to symptoms of headache resulting from migraine with aura attack to decrease risk of future migraines please continue to drink 2l of water daily get hours of sleep at night and do not skip meals we are changing your medications as follows for migraine prevention start verapamil mg daily at the onset of headache you can take a combination of naproxen compazine and diphenhydramine doses below this can be repeated after hours as needed please take your other medications as prescribed please follow up with neurology and your primary care physician as listed below if you experience any of the symptoms below please seek emergency medical attention by calling emergency medical services dialing in particular since stroke can recur please pay attention to the sudden onset and persistence of these symptoms sudden partial or complete loss of vision sudden loss of the ability to speak words from your mouth sudden loss of the ability to understand others speaking to you sudden weakness of one side of the body sudden drooping of one side of the face sudden loss of sensation of one side of the body sincerely your neurology team followup instructions

name unit no admission date discharge date date of birth sex f service neurology allergies codeine darvon aspirin advil attending chief complaint word finding difficulties major surgical or invasive procedure none history of present illness the pt is a year old f w hx of htn hld ovarian ca s p chemo and multiple surgical procedures who presents with language difficulties hx obtained from pt at bedside and daughter over phone of note pt is inconsistent historian pt was in usoh until on while working in she noticed difficulty finding her words in conversation she further elaborated as maintaining a conversation with others but stopping occasionally due to difficulty finding the right words to say upon going home later that evening she was called by her co workers who said she didn t seem like herself the next day pt went to see her sister who has with her language subjectively intact the following day she was playing bridge with some friends at the beauty shop when she began to have similar language difficulties although again reports she was still able participate in conversation she states she is not sure if sx persisted into next day as she was alone and did not interact with anyone on morning of presentation she again noticed these sx feeling that they were slightly worse she called her pcp s office who recommended she come to ed for evaluation collateral from daughter indicates that she spoke to pt over phone multiple times on evening multiple times during the day on and this morning she feels that pt had word finding issues as noted above but were more severe with pt stopping after every few words and unable to complete sentences she noticed that pt was frustrated with her language output she also was concerned that on a few occasions pt s speech was slurred no associated facial weakness visual changes or other focal deficits of note around the time of onset she also began to have gait difficulties pt denies recent chest pain dyspnea cough abdominal pain n v diarrhea dysuria or polyuria no clear triggers or atypical events last week prior to onset of her sx no recent difficulties with sleep or acute stressors at baseline she lives and ambulates independently however she did have fall weeks resulting in l distal radius fx no recent neck back pain parasthesias in extremities or bowel bladder dysfunction no similar sx in past neuro and general ros negative except as noted above past medical history pmh htn diagnosed anxiety depression recent denies h o thromboembolic disorder psh d c secondary to irregular bleeding cholecystectomy via laparotomy right ankle orif ob g2p2 nvd x2 gyn menarche age menopause mid h o fibroids denies h o previous ovarian cysts sti or abnormal pap social history family history paternal cousin died of breast cancer age maternal cousin als multiple family members have htn and cad denies family history of ovarian cancer endometrial cancer and colon cancer physical exam admission physical exam vitals t p bp rr o2sat ra general awake cooperative nad heent nc at no scleral icterus noted mmm no lesions noted in oropharynx neck supple no carotid bruits appreciated no nuchal rigidity pulmonary lungs cta bilaterally without r r w cardiac rrr nl s1s2 no m r g noted abdomen soft nt nd normoactive bowel sounds no masses or organomegaly noted extremities no c c e bilaterally radial dp pulses bilaterally l wrist splint in place skin no rashes or lesions noted mental status alert oriented x inconsistent historian attentive able to name backward without difficulty language is fluent with intact repetition and comprehension normal prosody there were no paraphasic errors pt was able to name both high and low frequency objects speech was not dysarthric able to follow both midline and appendicular commands pt was able to register objects and recall at minutes there was no evidence of apraxia or neglect cranial nerves ii iii iv vi perrl to 1mm and brisk eomi without nystagmus normal saccades vff to confrontation v facial sensation intact to light touch vii subtle decreased marionette line on l 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 orbiting no adventitious movements such as tremor noted no asterixis noted delt bic tri wre ffl fe io ip quad ham ta l r limited due to splint sensory no deficits to light touch pinprick or cold sensation inconsistent responses to vibratory sense and proprioception at level of great toe intact at medial malleoli b l no extinction to dss dtrs bi tri pat ach l r plantar response was wd bilaterally coordination no intention tremor no dysdiadochokinesia noted no dysmetria on fnf or ttf bilaterally gait significantly slowed initiation requiring person assistance to stand up from bed wide base w small stride unable to complete romberg due to significant sway with feet together discharge vitals t bp hr rr o2 ra general awake cooperative nad heent nc at no scleral icterus noted mmm no lesions noted in oropharynx neck supple no nuchal rigidity pulmonary breathing comfortably on room air cardiac wwp abdomen soft nt nd extremities wwp no obvious deformities skin no rashes or lesions noted mental status alert oriented x language is fluent with intact repetition and comprehension normal prosody pt was able to name both high and low frequency objects following commands cranial nerves ii iii iv vi perrl and brisk eomi without nystagmus v facial sensation intact to light touch vii facial droop improved unable to detect on today s exam 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 orbiting no adventitious movements such as tremor noted no asterixis noted delt bic tri wre ffl fe io ip quad ham ta l r sensory no deficits to light touch dtrs deferred finger to nose without dysmetria gait deferred pertinent results 31pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 49am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 05am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 31pm blood ptt 30am blood ptt 05am blood ptt 31pm blood glucose urean creat na k cl hco3 angap 30am blood glucose urean creat na k cl hco3 angap 14am blood glucose urean creat na k cl hco3 angap 05am blood glucose urean creat na k cl hco3 angap 31pm blood alt ast ck cpk alkphos totbili 30am blood alt ast ld ldh alkphos totbili 38am blood ck mb ctropnt 30am blood ck mb ctropnt 31pm blood albumin calcium phos mg 30am blood albumin calcium phos mg 49am blood calcium phos mg 05am blood calcium phos mg 38am blood vitb12 38am blood hba1c eag 38am blood triglyc hdl chol hd ldlcalc 38am blood tsh 31pm blood asa neg acetmnp neg tricycl neg 30am blood lactate 30am blood freeca imaging cta ct head without contrast there is no evidence of infarction hemorrhage edema ormass the ventricles and sulci are prominent consistent global cerebral volume loss patchy periventricular hypodensities are most consistent with chronic microvascular ischemic disease there is complete opacification of the right sphenoid sinus with aerosolized secretions seen superiorly there is severe narrowing of the right sphenoid ethmoidal recess there is mild mucosal thickening of the left sphenoid and the bilateral ethmoid sinuses the mastoid air cells are clear the patient is status post bilateral cataract surgery cta head atherosclerotic changes of the intracranial internal carotid arteries are seen without significant narrowing there is narrowing and irregularity likely atherosclerotic along the basilar artery otherwise the vessels of the circle of and their principal intracranial branches appear normal without stenosis occlusion or aneurysm formation there is fetal origin of the right posterior cerebral artery and fetal type origin of the left posterior cerebral artery a dominant right vertebral artery is seen the dural venous sinuses are patent cta neck a vessel arch is seen atherosclerotic changes of the carotid bifurcations are seen without narrowing of the internal carotid arteries by nascet criteria the vertebral arteries and their major branches appear normal with no evidence of stenosis or occlusion other the visualized portion of the lungs are clear a multinodular goiter is seen there is no lymphadenopathy by ct size criteria mild cervical spondylosis is seen impression severe right sphenoid sinus disease otherwise no acute intracranial abnormality intracranial atherosclerotic disease most prominent involving the basilar artery no other significant narrowing of the circle of arteries no internal carotid artery stenosis by nascet criteria multinodular goiter cta impression no acute intracranial hemorrhage or new large territory infarct noncalcified atherosclerosis irregularity of the basilar artery and atherosclerotic disease of cavernous segments of the bilateral ica unchanged from prior no other significant narrowing of the circle arteries multinodular goiter mri impression examination is mildly degraded by motion evolving left this pallidus subacute infarct without definite evidence of hemorrhagic transformation as described no evidence of new acute infarction moderate cerebral atrophy and chronic small vessel ischemic disease paranasal sinus disease as described above tte conclusion the left atrium is normal in size there is no evidence for an atrial septal defect by 2d color doppler the estimated right atrial pressure is mmhg there is normal left ventricular wall thickness with a normal cavity size there is suboptimal image quality to assess regional left ventricular function the visually estimated left ventricular ejection fraction is left ventricular cardiac index is normal l min m2 there is no resting left ventricular outflow tract gradient no ventricular septal defect is seen tissue doppler suggests an increased left ventricular filling pressure pcwp greater than 18mmhg normal right ventricular cavity size with normal free wall motion the aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender there is no evidence for an aortic arch coarctation the aortic valve leaflets are mildly thickened there is no aortic valve stenosis there is trace aortic regurgitation the mitral valve leaflets are mildly thickened with no mitral valve prolapse the transmitral e wave deceleration time is prolonged 250ms there is mild mitral regurgitation the tricuspid valve leaflets appear structurally normal there is physiologic tricuspid regurgitation the estimated pulmonary artery systolic pressure is normal there is a trivial pericardial effusion impression suboptimal image quality no intracardiac source of thromboembolism identified preserved global biventricular systolic function mild mitral regurgitation normal pulmonary pressure brief hospital course patient is a year old female with a history of hypertension hyperlipidemia type diabetes mellitus ovarian cancer s p chemo and surgical interventions who presents with word finding difficulties and recent falls subacute left globus pallidus infarct initial non contrast headache ct was negative for acute hemorrhage and alteplase was not administered due to extended duration of symptoms and thrombectomy was not done d t no large vessel occlusion mri head w contrast revealed a possible subacute infarct in left basal ganglia exam was notable for very subtle apraxia neglect and migrographia which the patient said was new she had mild hesitancy in her speech but no aphasia clinically the patient appeared to be improving however had two episodes on in which the patient experienced nausea and bradycardia heart rate in and was briefly unresponsive for a few seconds the first of these episodes began while the patient was walking with with bradycardia and unresponsiveness occurring after the patient lay down she regained conscious within a few seconds the second episode occurred while the patient was sitting in bed and included a second pause on telemetry with loss of consciousness left eye deviation left head turning and bilateral upper extremity shaking she regained consciousness in seconds and was noted to have new right facial droop right upper extremity weakness and fluent aphasia with word salad nihss at this time was imaging at that time including non contrast head ct and cta were unremarkable and following ct nihss improved to alteplase was not administered due fluctuating exam and rapid improvement exam continued to improve with only mild aphasia eeg was done that showed mild left sided slowing but no discharges or electrographic seizures likely episode of eye deviation head deviation and upper extremity shaking iso bradycarida and sinus pause was convulsive syncope mri head without contrast later revealed stable subacute infarct in the left globus pallidus without any new areas of infarct or hemorrhage stroke risk factors include tsh fasting lipid panel ldl and hba1c she was started on aspirin 81mg and her simvastatin was changed to atorvastatin 40mg likely etiology of stokes is small vessel lacunar cognitive decline felt that likely some of her symptoms were due to overlying dementia that may have been worsening as patient lives alone and per family recently stopped taking her medications b12 and rpr were checked and were normal unclear how well she has been functioning at home prior to this as she lives alone she also has had repeated falls at home which she is unable to describe or explain htn her hypertensive medications were held other than hctz to allow blood pressure to auto regulate she was noted to be intermittently hypertensive and her home medications were re started there were held again after syncope described above prior to discharge she was restarted on amlodipine but losartan and hctz were held syncope during hospitalization as described above she had had a series of episodes of bradycardia during the first episode she became unresponsive and was noted to be bradycardic to as low as the on telemetry with a second pause followed by subsequent hypertension and tachycardia up to the bpm range about minutes later she had a similar episode finally after she had been stabilized in bed a third episode of bradycardia occurred with a documented second pause and associated period of unresponsiveness after she recovered she had worsened aphasia as well as weakness and facial droop as described above telemetry was considered to be consistent with vagal etiology without nodal block she has no prior history of arrhythmias or conduction disease transthoracic echocardiogram was obtained which revealed normal biventricular systolic function no cardiac source of embolus ep cardiology was consulted and felt that these episodes were consistent with vasovagal and did not warrant any further investigation or intervention we discussed worry that this episode may have caused some increased hypoperfusion and re infarction iso new facial droop weakness and aphasia after syncope ep felt that since likely vasovagual there was no indication for pacemaker as this would not prevent the vasodilation associated with vasovagual and would not prevent hypoperfusion they felt that if highly symptomatic episodes continue even with vagal triggers minimized in the future all nodal blockade should be avoided she has been scheduled for cardiology follow up she was discharged with of hearts monitor diabetes glucose was monitored throughout stay and insulin administered on sliding scale hbga1c per daughter she has not been taking her medications for at least a the past week or so she was restarted on home metformin at discharge she has an endocrinology appointment scheduled for this month transitional issues patient has neurology appointment scheduled in with dr she can be referred to cognitive neurology at that time if she has decline in cognition patient should have holter monitor to assess for continued vagal syncope has cardiology outpatient follow up please avoid all nodal blockade in the future holding losartan and hctz due to lightheadedness on standing pcp to check bp in outpatient setting and manage medications aha asa core measures for ischemic stroke and transient ischemic attack dysphagia screening before any po intake x yes confirmed done not confirmed no if no reason why dvt prophylaxis administered x yes no if no why not i e bleeding risk hemorrhage etc antithrombotic therapy administered by end of hospital day x yes no if not why not i e bleeding risk hemorrhage etc ldl documented x yes ldl no intensive statin therapy administered simvastatin 80mg simvastatin 80mg ezetemibe 10mg atorvastatin 40mg or mg rosuvastatin 20mg or 40mg for ldl yes no if ldl reason not given statin medication allergy other reasons documented by physician advanced practice nurse physician physician apn pa or pharmacist ldl c less than mg dl smoking cessation counseling given yes x no reason x non smoker unable to participate 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 assessment for rehabilitation or rehab services considered x yes no if no why not i e patient at baseline functional status discharged on statin therapy x yes no if ldl reason not given statin medication allergy other reasons documented by physician advanced practice nurse physician physician apn pa or pharmacist ldl c less than mg dl discharged on antithrombotic therapy x yes type x antiplatelet anticoagulation no discharged on oral anticoagulation for patients with atrial fibrillation flutter yes no if no why not i e bleeding risk etc x n a medications on admission the preadmission medication list may be inaccurate and requires futher investigation amlodipine mg po daily hydrochlorothiazide mg po daily losartan potassium mg po daily hydrocortisone cream appl tp bid metformin glucophage mg po daily metformin glucophage mg po qpm simvastatin mg po qpm vitamin d unit po daily discharge medications aspirin mg po daily atorvastatin mg po qpm amlodipine mg po daily metformin glucophage mg po daily metformin glucophage mg po qpm vitamin d unit po daily discharge disposition extended care facility discharge diagnosis primary diagnosis ischemic stroke vasovagal syncope secondary diagnosis hypertension hyperlipidemia type diabetes mellitus osteoporosis stage iib grade ovarian ca s p ex lap tah bso pelvic tumor resection omentectomy and chemo in discharge condition mental status confused sometimes level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear ms you were hospitalized due to symptoms of language difficulties we think this is due to an ischemic stroke while you were admitted in the hospital you had an episode of impaired consciousness and were found to have low heart rate which led to new symptoms of difficulty talking these episodes are consistent with ischemic stroke a condition where the brain does not receive enough oxygen and nutrients 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 in addition there was concern that these episodes of low heart rate fainting were related to an abnormality in your heart so the cardiology and electrophysiology teams were consulted they felt these episodes were more likely due to an episode of increased vagal tone and we felt dehydration contributed so we gave you fluids after which your symptoms improved stroke can have many different causes so we assessed you for medical conditions that might raise your risk of having stroke in order to prevent future strokes we plan to modify those risk factors your risk factors are hypertension hyperlipidemia diabetes we are changing your medications as follows please stop taking losartan and hctz you can continue taking amlodipine until you see your primary care doctor we started aspirin mg daily we started atorvastatin mg daily please take your other medications as prescribed please follow up with neurology cardiology 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 in particular since stroke can recur please pay attention to the sudden onset and persistence of these symptoms sudden partial or complete loss of vision sudden loss of the ability to speak words from your mouth sudden loss of the ability to understand others speaking to you sudden weakness of one side of the body sudden drooping of one side of the face sudden loss of sensation of one side of the body sincerely your neurology team followup instructions

name unit no admission date discharge date date of birth sex f service neurosurgery allergies no known allergies adverse drug reactions attending chief complaint aneurysm major surgical or invasive procedure pipeline embolization of left ica aneurysm history of present illness she is a nurse that works in the in the dialysis unit she started noticing some tingling sensation on the right side of the face that did not disappear and work up obtained an mri mra the report came back positive for aneurysm fh for aneurysm she presents today for pipeline embolization of left ica aneurysm past medical history anxiety depression social history family history her father is diagnosed with a to mm aneurysm that he has actually been followed by dr here at she had also two second degree relatives with brain aneurysms physical exam on discharge x nad perrla 2mm cn ii xii intact ls clear rrr abdomen soft ntnd bue and ble no drift groin site clean dry intact without hematoma pertinent results please see omr for relevant imaging reports brief hospital course pipeline embolization of her left ica aneurysm on she was admitted to the neurosurgical service and under general anesthesia had a successful pipeline embolization of her left ica aneurysm her operative course was uncomplicated for further procedure details please see separately dictated operative report by dr she was extubated groin angiosealed and transferred to be recovered in the pacu and then transferred to the when stable on pod she remained stable she ambulated well independently and was discharged home medications on admission nuvaring lorazepam daily as needed sertraline mg daily brilinta bid aspirin discharge medications acetaminophen mg po q6h prn fever or pain no greater than grams of tylenol in hours aspirin mg po daily rx aspirin adult low dose aspirin mg one tablet s by mouth once a day disp tablet refills docusate sodium mg po bid hold for loose stool stop once done taking oxycodone oxycodone immediate release mg po q6h prn pain decrease use as pain improves request less than prescribed rx oxycodone mg one tablet s by mouth every six hours disp tablet refills senna mg po qhs hold for loose stools stop once done taking oxycodone ticagrelor mg po bid rx ticagrelor brilinta mg one tablet s by mouth twice a day disp tablet refills sertraline mg po daily discharge disposition home discharge diagnosis aneurysm discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions activity you may gradually return to your normal activities but we recommend you take it easy for the next hours to avoid bleeding from your groin heavy lifting running climbing or other strenuous exercise should be avoided for ten days this is to prevent bleeding from your groin you make take leisurely walks and slowly increase your activity at your own pace try to do too much all at once do not go swimming or submerge yourself in water for five days after your procedure you make take a shower medications resume your normal medications and begin new medications as directed you may be instructed by your doctor to take one a day and or plavix if so do not take any other products that have aspirin in them if you are unsure of what products contain aspirin as your pharmacist or call our office you may use acetaminophen tylenol for minor discomfort if you are not otherwise restricted from taking this medication if you take metformin glucophage you may start it again three days after your procedure care of the puncture site you will have a small bandage over the site remove the bandage in hours by soaking it with water and gently peeling it off keep the site clean with soap and water and dry it carefully you may use a band aid if you wish what you experience mild tenderness and bruising at the puncture site groin soreness in your arms from the intravenous lines mild to moderate headaches that last several days to a few weeks fatigue is very normal constipation is common be sure to drink plenty of fluids and eat a high fiber diet if you are taking narcotics prescription pain medications try an over the counter stool softener when to call your doctor at for severe pain swelling redness or drainage from the puncture site fever greater than degrees fahrenheit constipation blood in your stool or urine nausea and or vomiting extreme sleepiness and not being able to stay awake severe headaches not relieved by pain relievers seizures any new problems with your vision or ability to speak weakness or changes in sensation in your face arms or leg followup instructions

name unit no admission date discharge date date of birth sex f service orthopaedics allergies latex attending chief complaint left tibial shaft fracture major surgical or invasive procedure placement of left tibial intramedullary nail on history of present illness w left distal tib fib shaft fx on while ice skating presents for left heel pain x days she was seen at originally but followed with dr in clinic on and had long leg cast applied and wedged for the past days she has had increasing pain at the heel and tightness of the toes enough now that the pain is waking her from sleep despite pain meds and elevation she called the answering service and i advised her to come in due to the possibility of a heel sore the patient is scheduled to see dr on to likely plan im nailing of the tibia which she is more amenable to now given the difficulty getting around with the long leg cast she denies any numbness or tingling she has not taken oxycodone for several days but continues to take tylenol around the clock otherwise feels well and denies any fevers chills chest pain or shortness of breath of note patient reports that she had a ct scan of the ankle at and it was on the disc that she brought to clinic the patient was evaluated in clinic on and decided that she would no longer like to pursue closed treatment and elected for surgical intervention the risks benefits indications for surgery were thoroughly discussed with the patient and she elected to undergo surgery which was scheduled for past medical history migraines pvcs social history family history nc physical exam upon admission general well appearing female in no acute distress left lower extremity long leg cast clean dry and intact without skin breakdown at the edges i bivalved the entire long leg cast and reinforced the cast with tape i also removed the entire heel portion of the cast exposing the skin to reveal a x cm stage i pressure ulcer without a break in the skin or surrounding erythema or drainage wiggles exposed toes silt exposed toes toes wwp with bcr upon discharge general well appearing breathing comfortably on ra detailed examination of lle ace dsg cdi fires fhl ta gcs silt n distributions wwp distally pertinent results please see omr for pertinent labs and studies 45am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 45am blood glucose urean creat na k cl hco3 angap 45am blood calcium phos mg brief hospital course the patient presented as a same day admission for surgery the patient was taken to the operating room on for placement of left intramedullary nail which the patient tolerated well for full details of the procedure please see the separately dictated operative report the patient was taken from the or to the pacu in stable condition and after satisfactory recovery from anesthesia was transferred to the floor the patient was initially given iv fluids and iv pain medications and progressed to a regular diet and oral medications the patient was given antibiotics and anticoagulation per routine the patient s home medications were continued throughout this hospitalization the patient worked with who determined that discharge to home was appropriate the hospital course was otherwise unremarkable at the time of discharge the patient s pain was well controlled with oral medications incisions were clean dry intact and the patient was voiding moving bowels spontaneously the patient is weight bearing as tolerated in the left lower extremity and will be discharged on aspirin 325mg daily x4weeks for dvt prophylaxis the patient will follow up with dr routine a thorough discussion was had with the patient regarding the diagnosis and expected post discharge course including reasons to call the office or return to the hospital and all questions were answered the patient was also given written instructions concerning precautionary instructions and the appropriate follow up care the patient expressed readiness for discharge medications on admission none discharge medications acetaminophen mg po q6h rx acetaminophen mg tablet s by mouth three times daily disp tablet refills aspirin mg po daily rx aspirin mg tablet s by mouth daily disp tablet refills bisacodyl mg po pr daily prn constipation rx bisacodyl mg tablet s by mouth daily disp tablet refills calcium carbonate mg po tid rx calcium carbonate mg calcium mg tablet s by mouth daily disp tablet refills docusate sodium mg po bid rx docusate sodium mg tablet s by mouth twice daily disp tablet refills multivitamins tab po daily oxycodone immediate release mg po q4h prn pain rx oxycodone mg to tablet s by mouth every four hours disp tablet refills senna mg po daily rx sennosides senna mg tab by mouth daily disp tablet refills vitamin d unit po daily rx ergocalciferol vitamin d2 unit tablet s by mouth daily disp tablet refills discharge disposition home with service facility diagnosis left tibial shaft fracture discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions instructions after orthopaedic surgery you were in the hospital for orthopedic surgery it is normal to feel tired or washed out after surgery and this feeling should improve over the first few days to week resume your regular activities as tolerated but please follow your weight bearing precautions strictly at all times activity and weight bearing weightbearing as tolerated to the left lower extremity medications please take all medications as prescribed by your physicians at discharge continue all home medications unless specifically instructed to stop by your surgeon do not drink alcohol drive a motor vehicle or operate machinery while taking narcotic pain relievers narcotic pain relievers can cause constipation so you should drink eight 8oz glasses of water daily and take a stool softener colace to prevent this side effect anticoagulation please take aspirin 325mg daily for weeks wound care you may shower no baths or swimming for at least weeks any stitches or staples that need to be removed will be taken out at your week follow up appointment please remain in your dressing and do not change unless it is visibly soaked or falling off splint must be left on until follow up appointment unless otherwise instructed do not get splint wet danger signs please call your pcp or surgeon s office and or return to the emergency department if you experience any of the following increasing pain that is not controlled with pain medications increasing redness swelling drainage or other concerning changes in your incision persistent or increasing numbness tingling or loss of sensation fever shaking chills chest pain shortness of breath nausea or vomiting with an inability to keep food liquid medications down any other medical concerns this patient is expected to require days of rehab physical therapy weightbearing as tolerated to left lower extremity treatments frequency any staples or superficial sutures you have are to remain in place for at least weeks postoperatively incision may be left open to air unless actively draining if draining you may apply a gauze dressing secured with paper tape you may shower and allow water to run over the wound but please refrain from bathing for at least weeks postoperatively please remain in the splint until follow up appointment please keep your splint dry if you have concerns regarding your splint please call the clinic at the number provided call your surgeon s office with any questions followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies zoloft attending chief complaint chest pain major surgical or invasive procedure none history of present illness dr is a surgeon at with past medical history notable for coronary artery disease cad s p cabg and several pci s since then most recent balloon angioplasty svg om who presents with days of chest pain exam in the ed notable for bilateral lower extremity edema ecg showed v pacing at bpm intermittent ectopy sgarbossa negative pocus tte showed ef no apparent rwma in the ed initial vitals were temp hr bp rr ra ecg showed v pacing at bpm intermittent ectopy sgarbossa negative pocus tte showed ef no apparent wall motion abnormality labs studies notable for wbc hg hct platelets mcv chemistry notable for na k cl bicarb bun cr glucose trop mb ck pro bnp inr cxr showed small right pleural effusion with patchy bibasilar airspace opacities possibly atelectasis though infection is not excluded mild pulmonary vascular congestion patient was given mg aspirin mg nitro unit heparin evaluated by cardiology consult who recommended treatment as unstable angina with initiation of heparin gtt without bolus already on apixaban recommendation to hold apixaban make npo after midnight recommendation for nuclear stress test in am if chest pain overnight start sublingual nitro or nitro gtt and consider cardiac cath at that time vitals on transfer hr bp rr ra on the floor dr that he has had ongoing chest pressure in his mid chest for days both with exertion and at rest the pressure also radiates to his left wrist with associated numbness tingling he denies any associated dyspnea diaphoresis feeling lightheaded or dizziness he notes that his chest pressure has improved with nitroglycerin he is currently chest pain free he does endorse a few episodes of vomiting without diarrhea abdominal pain or fevers unrelated to his chest pressure over the last few days of note he has not taken his eliquis the past days as he has planned injection on for chronic back pain past medical history angina pectoris post cabg and post multiple stents ptca atrial fibrillation benign prostatic hypertrophy gastroesophageal reflux osteoarthritis pacemaker chronic obstructive pulmonary disease back and neck pain turp knee surgery social history family history there is no family history of premature coronary artery disease or sudden death physical exam admission exam vs t bp hr manual recheck s rr o2 sat ra general in nad oriented x3 mood affect appropriate heent ncat sclera anicteric perrl eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthelasma neck supple without jvd cardiac normal s1 s2 no murmurs rubs gallops no thrills lifts chest raised erythematous papule stable from baseline well healed surgical scar lungs no chest wall deformities scoliosis or kyphosis resp were unlabored no accessory muscle use no crackles wheezes or rhonchi abdomen soft ntnd no hsm or tenderness lipoma on right lower quadrant skin no stasis dermatitis ulcers scars or xanthomas pulses distal pulses palpable and symmetric discharge exam vs temp hr bp rr ra tele paced occ pvc s general nad a ox3 pleasant laying down in bed heent sclera anicteric oropharynx clear neck no jvd cv rrr no murmurs normal pmi lungs clear bilaterally abdomen ntnd bs ext warm and well perfused no edema neuro grossly normal pertinent results admission labs 06pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 04pm blood ptt 06pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 06pm blood glucose urean creat na k cl hco3 angap 06pm blood ck mb probnp 06pm blood ctropnt 25am blood ck mb ctropnt 00am blood ck mb ctropnt 06pm blood calcium phos mg discharge labs 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood ptt 00am blood glucose urean creat na k cl hco3 angap 00am blood calcium phos mg reports pharmacologic stress test normal myocardial perfusion increased left ventricular cavity size with mild global systolic dysfunction compared with prior study of the prior apical defect is no longer present left ventricular cavity size has increased and systolic function has decreased cxr small right pleural effusion with patchy bibasilar airspace opacities possibly atelectasis though infection is not excluded mild pulmonary vascular congestion brief hospital course y o m cardiac surgeon with a h o cad s p cabg and pci s a fib ppm copd gerd presenting with several days of chest pain concerning for unstable angina active issues chest pain presented with t rest relieved by nitro given his significant cardiac history there was concern for unstable angina he was started on a heparin drip and given full dose asa on arrival and his home apixaban was held he was chest pain free after admission there were no ischemic ekg changes troponin and ck mb were negative x3 stress mibi was done showing normal perfusion and a decrease in systolic function to vs his prior study he was discharged home with plan for an outpatient catheterization in days home imdur was increased from 60mg daily to 120mg daily continued home metoprolol succinate 25mg daily asa 81mg and atorvastatin 40mg daily chronic issues h o a fib s p pacemaker for tachy brady takes apixaban for anticoag as outpatient but this has been held in anticipation of a pain injection procedure on heparin drip was used for anticoag while inpatient copd lung exam unremarkable normal rr and o2 sats continued home symbicort bid tiotropium albuterol inhaler prn anemia microcytic stable during this admission stable vs prior labs earlier this year prior workup c w iron deficiency back neck pain continued home duloxetine 30mg daily hydrocodone acetaminophen prn gerd pantoprazole 40mg daily hypothyroidism levothyroxine mcg daily transitional issues imdur increased from mg daily to mg daily at discharge will follow up with dr likely receive an angiogram in days request was sent and timing being finalized with dr apixiban held on discharge as it had been held prior to admission in anticipation of upcoming back procedure on it will also be held in anticipation of upcoming angiogram to be determined by dr medications on admission the preadmission medication list is accurate and complete albuterol inhaler puff ih bid prn sob apixaban mg po bid atorvastatin mg po qpm symbicort budesonide formoterol mcg actuation inhalation bid duloxetine mg po daily isosorbide mononitrate mg po daily levothyroxine sodium mcg po daily metoprolol succinate xl mg po daily endocet oxycodone acetaminophen mg oral q6 prn pain pantoprazole mg po q24h tiotropium bromide cap ih daily aspirin mg po daily nitromist nitroglycerin mcg spray translingual sprays q5 minutes prn chest pain discharge medications albuterol inhaler puff ih bid prn sob aspirin mg po daily atorvastatin mg po qpm duloxetine mg po daily levothyroxine sodium mcg po daily metoprolol succinate xl mg po daily nitromist nitroglycerin mcg spray translingual sprays q5 minutes prn chest pain pantoprazole mg po q24h symbicort budesonide formoterol mcg actuation inhalation bid tiotropium bromide cap ih daily endocet oxycodone acetaminophen mg oral q6 prn pain isosorbide mononitrate mg po bid discharge disposition home discharge diagnosis primary unstable angina secondary coronary artery disease atrial fibrillation discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear dr was a pleasure participating in your care at you were admitted to our hospital because of chest pain we checked your troponins which we negative three times ruling out a heart attack a pharmacologic cardiac perfusion study showed normal perfusion and a mild decrease in systolic function dr about these results and will follow up with you as an outpatient he may recommend an angiogram we wish you all the best your care team followup instructions

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 cardiac catherization l3 l4 arterial embolization history of present illness dr is a year old cardiac surgeon with past history of cad s p cabg and several pci s and most recently balloon angioplasty svg om presents with increased chest pain patient was recently admitted on to medicine and discharged on patient re presented to the ed for recurrent chest pain symptoms over the past days patient has been having increased chest pain and reports that this has been increased with exertion he also had radiation of this chest pain to the left hand with associated numbness tingling he denies any dyspnea orthopnea lightheaded or dizziness he did have some episodes several days ago of chest pain with vomiting however none currently he felt nauseous in the ed with no vomiting notably patient does take apixiban for atrial fibrillation anticoagulation and patient has not been taking this medication due to a planned steroid injection on for back pain during patient s prior hospitalization he was initially started on heparin gtt and given aspirin full dose patient was found to be chest pain free after sl nitro and ekg at that time was not notable for any ischemic change patient underwent a stress mibi which did show normal perfusion a decrease in ef to and therefore was then discharged for outpatient follow up patient s home medications were also changed to imdur mg from mg given his home metoprolol ed course in the ed patient had initial labs that were notable for a trop t sodium potassium chloride bun createinine patient was then found to have lfts alt ast ap patient also had hgb hct with mcv and wbc patient was then taken to the cardiac cath lab for urgent evaluation of unstable angina there it was visualized that the graft to the om was down and collaterals looked good there was further discussion regarding further revascularization and possible medical vs operative treatment past medical history angina pectoris post cabg and post multiple stents ptca atrial fibrillation benign prostatic hypertrophy gastroesophageal reflux osteoarthritis pacemaker chronic obstructive pulmonary disease back and neck pain turp knee surgery social history family history there is no family history of premature coronary artery disease or sudden death physical exam admission physical examination vs 2l general nad very sleepy after catherization heent ncat sclera anicteric perrl eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthelasma neck supple no jvd cardiac rrr no murmurs rubs gallops no thrills lifts lungs no chest wall deformities scoliosis or kyphosis resp were unlabored no accessory muscle use no crackles occasional wheezes in left lower base no rhonchi abdomen soft ntnd no hsm or tenderness extremities no c c e no femoral bruits skin no stasis dermatitis ulcers scars or xanthomas pulses distal pulses palpable and symmetric discharge physical examination deceased pertinent results admission labs 00am ptt 00am plt count 00am wbc rbc hgb hct mcv mch mchc rdw rdwsd 00am calcium phosphate magnesium 00am ck mb ctropnt 00am glucose urea n creat sodium potassium chloride total co2 anion gap 00am ctropnt 00am glucose urea n creat sodium potassium chloride total co2 anion gap 09pm ptt 09pm plt count 09pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 09pm calcium phosphate magnesium imaging echo the left atrium is moderately dilated there is mild symmetric left ventricular hypertrophy with normal cavity size overall left ventricular systolic function is low normal lvef secondary to septal dyssynchrony doppler parameters are indeterminate for left ventricular diastolic function the right ventricular cavity is mildly dilated with focal hypokinesis of the apical free wall there is abnormal septal motion position consistent with right ventricular pressure volume overload the number of aortic valve leaflets cannot be determined the mitral valve leaflets are mildly thickened there is no mitral valve prolapse mild mitral regurgitation is seen moderate to severe tricuspid regurgitation is seen there is severe pulmonary artery systolic hypertension there is no pericardial effusion compared with the prior study images reviewed of the right ventricle is now dilated with evidence of apical hypokinesis there is more tricuspid regurgitation and pulmonary artery systolic pressure is severely increased left ventricular regional global systolic function and other findings are similar cta chest w w o c recon no evidence of pulmonary embolism or acute aortic syndrome small consolidations in the right upper lobe and right lower lobe in a dependent location with a moderate right pleural effusion underlying infection not excluded left basilar atelectasis pooling of secretions above the ett balloon head ct no evidence of acute intracranial process chest portable ap study date of mild pulmonary edema has increased since slight increase in severe cardiomegaly could be due to differences in cardiac cycle small right pleural effusion is likely there is no pneumothorax new et tube is in standard placement esophageal drainage tube ends in the upper portion of a nondistended stomach transvenous right atrial right ventricular pacer leads follow their expected courses from the left pectoral generator cta chest w w o c recons non coronarystudy date of no evidence of pulmonary embolism or acute aortic syndrome small consolidations in the right upper lobe and right lower lobe in a dependent location with a moderate right pleural effusion underlying infection not excluded left basilar atelectasis pooling of secretions above the ett balloon liver or gallbladder us single organ portstudy date of normal liver echotexture with patent flow of the portal vein no concerning liver mass no morphologic features of cirrhosis trace left lower quadrant ascites cholelithiasis with trace pericholecystic fluid but no wall thickening partially visualized right pleural effusion chest portable ap study date of increased opacity at the right lung base likely reflects a layering pleural effusion severe cardiomegaly and pulmonary vascular congestion similar when compared to the prior study asymmetric pulmonary edema predominately affecting the right lung eegstudy date of this is an abnormal continuous icu eeg monitoring because of frontally predominant sharp waves with a triphasic morphology at times appear in periodic runs embedded on a diffusely slow background this is indicative of a moderate encephalopathy which is non specific but may be due to metabolic or electrolyte disturbances infection or medications there no definite epileptiform discharges there are no electrographic seizures mr head w o contraststudy date of few scattered punctate foci of slow diffusion in the left frontal centrum semiovale right occipital lobe and right cerebellum in keeping with acute infarcts likely embolic in etiology diffuse age related volume loss carotid series completestudy date of mild heterogeneous calcified plaque involving bifurcations bilaterally no hemodynamically significant stenoses on either side less than normal antegrade flow both vertebral arteries ct head w o contraststudy date of study is moderately degraded by motion within limits of study no evidence of acute intracranial hemorrhage hemorrhage or infarct chest portable ap study date of moderate edema with new asymmetric increased edema in the right upper lobe which can be seen in the setting of mitral regurgitation correlate with clinical history cta chest w w o c recons non coronary study date of active bleeding into a large left retroperitoneal hematoma most likely arising from the psoas muscle acute anterior fractures of the left fourth seventh and right fifth seventh ribs moderate right and small left pleural effusions with adjacent atelectasis ground glass opacities in the bilateral upper lobes may reflect aspiration chronic findings of colon diverticulosis and cholelithiasis chest portable ap study date of since most recent radiograph there is no significant interval change again seen is bilateral pleural effusion and atelectasis not significantly changed from prior the et tube now terminates approximately cm from the carina which may be due to patient positioning otherwise there is no appreciable change in support lines sternotomy wires and surgical clips are in place impression no significant interval change micro am urine source catheter final report urine culture final enterococcus sp organisms ml sensitivities mic expressed in mcg ml enterococcus sp ampicillin s nitrofurantoin s tetracycline r vancomycin s am sputum site endotracheal source endotracheal final report gram stain final pmns and epithelial cells 100x field no microorganisms seen quality of specimen cannot be assessed respiratory culture final commensal respiratory flora absent yeast sparse growth pm bronchoalveolar lavage bronchial lavage gram stain final per 1000x field polymorphonuclear leukocytes no microorganisms seen respiratory culture final ml commensal respiratory flora yeast organisms ml legionella culture preliminary no legionella isolated immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii fungal culture preliminary pm rapid respiratory viral screen culture bronchial lavage respiratory viral culture preliminary respiratory viral antigen screen final greater than polymorphonuclear leukocytes inadequate specimen for dfa detection of respiratory viruses interpret all negative dfa and or culture results from this specimen with caution urine culture negative blood culture negative mrsa negative sputum culture negative sputum culture rp stool c diff negative pm blood culture blood culture routine preliminary staphylococcus epidermidis isolated from only one set in the previous five days work up per coag neg staph does not require contact precautions regardless of resistance oxacillin resistant staphylococci must be reported as also resistant to other penicillins cephalosporins carbacephems carbapenems and beta lactamase inhibitor combinations rifampin should not be used alone for therapy staphylococcus epidermidis morphology isolated from only one set in the previous five days work up per coag neg staph does not require contact precautions regardless of resistance oxacillin resistant staphylococci must be reported as also resistant to other penicillins cephalosporins carbacephems carbapenems and beta lactamase inhibitor combinations rifampin should not be used alone for therapy sensitivities mic expressed in mcg ml staphylococcus epidermidis staphylococcus epidermidis clindamycin r s erythromycin r r gentamicin i s levofloxacin r oxacillin r r rifampin s s vancomycin s s aerobic bottle gram stain final gram positive cocci in clusters discharge labs 15am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 15am blood glucose urean creat na k cl hco3 angap 15am blood calcium phos mg 44am blood lactate 44am blood freeca 55pm urine blood mod nitrite neg protein glucose neg ketone neg bilirub neg urobiln neg ph leuks sm brief hospital course dr is an year old male with past history of cad s p cabg and multiple stenting nd most recently balloon angioplasty svg om and atrial fibrillation who presented with increased chest pain concerning for unstable angina unstable angina patient has now had another presentation of unstable angina at home with increased chest pain at rest patient was recently admitted and underwent stress test which was negative for ischemic area of disease patient was placed on heparin gtt for cardiac catherization which revealed that the svg to om1 was completed occluded proximally the decision was made not to place a stent since it appeared to be an old occlusion days and his initial troponions and mb were negative and there were no ischemic changes on ekg the plan was to optimize medical management with imdur renexa bid atorvastatin metoprolol aspirin and then continue to have discussion with outpatient cardiologist regarding further management however the patient began to have rising troponins on several hours after the catherization and then went into pea arrest and required intubation and transfer to the ccu for management ccu course patient underwent pea arrest in the evening of the patient developed sudden onset respiratory distress and ams he subsequently suffered a pea arrest with cpr performed and rosc after 5min cta ruled out pe but showed small rul consolidation vs compressive atelectasis and a moderate r pleural effusion at the time of transfer to the ccu the pt was on levophed for hypotension in the evening of eveloped fever and was ordered for ctx to treat uti due to a positive urinalysis the urine culture eventually grew enterococcus sensitive to vanc and unasyn on the pt remained febrile and vancomycin was added unasyn was added on for possible aspiration pneumonia he continued to spike fevers up to daily so he also received a dose of cefepime on and a dose of azithromycin on on id was consulted and recommended discontinuation of all antibiotics given likelihood of drug fever rather than an infectious etiology the patient had no further fevers after the pt was increasing agitated on the vent and unable to arouse when sedation weaned so he underwent evaluation by neurology with concern for anoxic injury an mri showed evidence of several foci of small embolic strokes eeg c w toxic metabolic encephalopathy the pt was noted to have bloody secretions on during suctioning at this time the pt s fever curve increased with a tm of sputum cx revealed gpcs on gram stain and given concern for aspiration ctx was d c and unasyn was initiated bloody secretions increased in quantity on and and the pt was evaluated by pulmonology who felt that they were related to irritation by the et tube compounded by anticoagulation and possible pneumonia on unasyn was broadened to cefepime the ccu team was unable to wean him from mechanical ventilation for several days due to the patient s inability to follow commands even off sedation as well as periods of agitation and tachypnea with low tidal volumes on he was noted to be alert and following commands he was eventually able to be extubated on post extubation the patient was awake talking and mostly responding to commands and interacting with his family the following day he was talking to his family members and calling them by name talking about distant past events appropriately overall he appeared to be dramatically improved towards the evening of however he was restless agitated more paranoid would not sleep despite his family urging by his agitation had worsened and the ccu team needed to give frequent doses of antipsychotics to help control this they discontinued his foley on overnight he required ongoing antipyschotics olanzapine haldol and seroquel and was even tried on precedex between 6pm and 6am without good effect of note the patient had a fever to in the am of his last fever prior to this was when antibiotics were discontinued and was straight catheterized yielding 300cc with a ua that was abnormal wbcs epi though ucx was negative he also was hypoxemic to mid 80s off nasal cannula mid 90s on nc lastly at 30am his pupils were noted to be unequal so a stat neuro consult was obtained their assessment was that this was most likely due to medication effect from ipratropium anticholinergic and albuterol beta agonist nebulizers this morning as well as precedex alpha agonist ct head was ordered which did not reveal any acute intracranial hemorrhage or infarct pt was given cogentin for possible parksinonian side effects from antipsychotics which may have been contributing to his fevers duloxetine and all anti psychotics were dc d on pt was noted to be increasingly tachypneic and agitated and had a pea arrest w rosc after 5min of cpr amps of bicarb a crash femoral line was placed and levophed was started for bp support and aline was later placed after pt stabilized no hypothermia was done per pt s family decision pt was noted to have a lactate of after the arrest which quickly downtrended later in the day pt s hypernatremia noted to have worsened was started on increasing ivf and fwf with lasix for fluid overload as needed ampillicin and flagyl was started for possible pna uti coverage later broadened to meropenem for increased coverage meropenem dc d on negative cultures and pt w o sig fevers pulm was c s for bal study noted not to find any significant findings for acute lung process pt remained tachypneic while intubated was weaned off propofol to precedex tried using ativan to control tachypnea though was unsuccessful had to be placed on rate control as wasn t tolerating pressure support pt failed sbt on in the early am of pt developed significant hypotension large abdominal mass was palpated pt got stat ct a showing significant brisk rp bleed went to stat for emergent embolization of l3 l4 arteries heparin gtt was stopped got protamine and blood product transfusions 5u prbcs 2x ffp d w family that day pt was made dnr if he were to arrest pt continued to spike fevers there was concern for infected hematoma and was started on dapto meropenem pt passed his rsbi on though there was continued concern for agitation after potential extubation which occurred on palliative care was consulted after extubation pt was made dni in addition to prior dnr abx and po meds were dc d pt was made comfortable w precedex and fentanyl boluses and levophed was stopped in the evening of pt was noted to have worsening respirations and be increasingly hypotensive and expired at medications on admission the preadmission medication list may be inaccurate and requires futher investigation albuterol inhaler puff ih bid prn sob aspirin mg po daily atorvastatin mg po qpm duloxetine mg po daily levothyroxine sodium mcg po daily metoprolol succinate xl mg po daily nitromist nitroglycerin mcg spray translingual sprays q5 minutes prn chest pain pantoprazole mg po q24h symbicort budesonide formoterol mcg actuation inhalation bid tiotropium bromide cap ih daily endocet oxycodone acetaminophen mg oral q6 prn pain isosorbide mononitrate mg po bid discharge medications deceased discharge disposition expired discharge diagnosis primary nstemi s p 2x pea respiratory arrest rp bleed hyperactive toxic metabolic encephalopathy afib uti secondary copd gerd hypothyroidism discharge condition deceased discharge instructions deceased followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies penicillins erythromycin base clindamycin bactrim ds sulfa sulfonamide antibiotics nitrofurantoin nsaids non steroidal anti inflammatory drug aspirin levaquin attending chief complaint fever fatigue major surgical or invasive procedure none history of present illness from admission note ms is a with history of migraines w pain protocol ms ckd hyperparathyroidism depression presenting with day of fever and generalized malaise and fatigue she states that she was feeling well up to the day prior to admission fairly quickly she started to feel generally unwell with chills in the afternoon she had sore throat nasal congestion cough no emesis diarrhea abdominal pain in the ed initial vs were 4l nc exam notable for fatigued sleeping easily arousable and conversant interacting per baseline lungs clear to auscultation bilaterally abd soft nontender back no cva tenderness ext no swelling no pitting edema labs showed wbc pmns creatinine baseline lactate imaging showed cxr impression chronic bibasilar atelectasis without definite focal consolidation consults none patient received po ng oseltamivir mg iv ceftriaxone started iv ceftriaxone stopped iv promethazine mg iv diphenhydramine mg iv hydromorphone dilaudid mg iv hydromorphone dilaudid mg iv ondansetron mg po ng oseltamivir mg iv ondansetron mg im promethazine mg po ng diphenhydramine mg iv hydromorphone dilaudid mg iv ondansetron mg im promethazine mg iv hydromorphone dilaudid mg po ng oseltamivir mg iv hydromorphone dilaudid mg iv ondansetron mg transfer vs were ra flu a came back positive in the ed and the patient was given oseltamivir there was initially some question of super imposed bacterial pneumonia and ceftriaxone was started but given equivocal cxr this was stopped the patient also developed a migraine in the ed this was managed w existing pain protocol iv dilaudid additional zofran on arrival to the floor patient reports the pain has improved somewhat now down from significant nausea moderate cough no visual symptoms no chest pain dyspnea dizziness past medical history from admission note multiple sclerosis in remission not on treatment hyperparathyroid migraine headache chronic renal insufficency to hx lithium use baseline cr hypercholesterolemia hypothyroid lithium depression s p tah bso social history family history from admission note heart disease father died age paternal grandfather heart mother at age died cva mother brother father since age paternal aunt paternal grandmother suicide two distant paternal family members and paternal aunt lung grandfather physical admission physical exam vs bp hr rr o2 sat on ra general nad heent at nc eomi heart rrr s1 s2 no murmurs gallops or rubs lungs ctab abdomen nondistended nontender in all quadrants extremities no cyanosis clubbing or edema neuro a ox3 moving all extremities with purpose quite sleepy but not somnolent skin warm and well perfused no excoriations or lesions no rashes dischare physical exam t bp hr rr o2 ra general nad lying in bed heent anicteric oropharynx clear neck supple no lad heart rrr s1 s2 no m r g lungs unlabored rare late inspiratory crackle abdomen soft nondistended nontender ext wwp without edema neuro non focal pertinent results admssion labs 47pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 47pm blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 47pm blood glucose urean creat na k cl hco3 angap 54pm blood lactate 12pm other body fluid fluapcr positive flubpcr negative discharge labs 05am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 05am blood glucose urean creat na k cl hco3 angap 05am blood calcium phos mg imaging cxr impression chronic bibasilar atelectasis without definite focal consolidation brief hospital course female with history of ckd stage iiib and migraine disorder presenting with fever fahrenheit and generalized malaise of one day duration found to be influenza a positive influenza fever on background constitutional symptoms as above of less than hour duration oseltamivir mg bid thus initiated on in the emergency department empiric ceftriaxone likewise initiated for possible bacterial superinfection which was then discontinued at admission in the absence of fever leukocytosis or hemodynamic instability no respiratory distress or hypoxemia noted cxr also reassuring patient quickly tolerated oral intake and was overall well enough for discharge by end of hospital day discharged on oseltamivir mg bid given gfr for completion of five day course end date migraine disorder intermittent typical migraine symptoms on the order of days prompting initiation of established pain protocol in the emergency department this was discontinued at admission for excessive sedation many of her sedating home medications were also held acute on chronic kidney disease secondary to lithium toxicity creatinine at presentation from baseline creatinine which rapidly declined with intravenous hydration and improved oral intake transitional issues confirm completion of five day course of oseltamivir end date consider de escalation of psychoactive medications and amending emergency migraine pain protocol from given excessive sedation greater than minutes spent in care coordination and counseling on the day of discharge contact husband code full presumed medications on admission the preadmission medication list may be inaccurate and requires futher investigation sodium bicarbonate mg po bid gabapentin mg po qhs topiramate topamax mg po qhs bupropion mg po bid aripiprazole mg po daily quetiapine fumarate mg po qhs clonazepam mg po qhs alprazolam mg po bid prn anxiety simvastatin mg po qpm multivitamins tab po daily promethazine id prn migraine nystatin cream appl tp tid calcitriol mcg po 1x week fr tamsulosin mg po qhs zolmitriptan mg oral daily prn levothyroxine sodium mcg po daily discharge medications oseltamivir mg po bid rx oseltamivir mg capsule s by mouth twice a day disp capsule refills alprazolam mg po bid prn anxiety aripiprazole mg po daily bupropion mg po bid calcitriol mcg po 1x week fr clonazepam mg po qhs gabapentin mg po qhs levothyroxine sodium mcg po daily multivitamins tab po daily nystatin cream appl tp tid promethazine id prn migraine quetiapine fumarate mg po qhs simvastatin mg po qpm sodium bicarbonate mg po bid tamsulosin mg po qhs topiramate topamax mg po qhs zolmitriptan mg oral daily prn discharge disposition home discharge diagnosis primary influenza secondary acute on chronic kidney injury migraine disorder discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms it was a pleasure caring for you at why was i admitted to the hospital you were diagnosed with the flu what happened while i was in the hospital you received an antiviral medication called tamiflu to shorten the duration of your symptoms we monitored your breathing and oxygen levels which remained normal you received fluids because you were not drinking well what should i do when i leave the hospital please take tamiflu until more days follow up with dr within one week get plenty of rest and remain well hydrated we wish you all the best sincerely your care team followup instructions

name unit no admission date discharge date date of birth sex m service neurology allergies penicillins topamax attending chief complaint vertigo major surgical or invasive procedure n a history of present illness is a yo man with history of relapsing remitting ms on chronic central vertigo obesity and dmii on lantus and metformin referred to the ed for worsening vertigo ms flare he reports over the last weeks has deteriorated to the point that he is not able to drive and apparently now can hardly get out of his chair to go to the bathroom he saw his neurologist dr in clinic this week after the symptoms worsened at the time she wanted to arrange an admission for steroids but he declined as he was moving to another apartment with his wife has been having constant vertigo and nausea for approximately years the symptoms improve somewhat but never go away completely he describes his dizziness as a sensation of the room is still but his head is spinning associated with nausea without vomiting symptoms are not better with closing eyes he notices still has the head spinning while in bed but denies worsening with turning in bed at baseline he walks with a cane denies visual changes denies ringing in his ears and loss of hearing he reports on wed he was moving so refused admission but today felt worse so finally agreed to come in he has been taking zofran twice daily for the nausea also notes chronic paresthesias over his hands and fingertips reports baseline left leg weakness for which he walks with a cane he reports initial ms symptoms presented with optic neuritis at age he was diagnosed much later at y o during that episode he remembers was working in an office and developed word finding difficulty as well as numbness in his and bilateral fingers at the time a neurologist at diagnosed him with ms then he has been followed by dr he reports has not been admitted frequently to the hospital for management of flares past medical history dm ms cancer s p radiation migraines on propranolol for prophylaxis social history family history mother dm father dm cad physical exam admission physical exam general nad well appearing man heent ncat no oropharyngeal lesions neck supple rrr no m r g pulmonary ctab no crackles or wheezes abdomen soft nt nd bs no guarding extremities warm no edema neurologic examination mental status awake alert oriented x able to relate history without difficulty attentive able to name backward without difficulty speech is fluent with full sentences intact repetition and intact verbal comprehension naming intact no paraphasias no dysarthria normal prosody able to register objects and recall at minutes no apraxia no evidence of hemineglect no left right confusion able to follow both midline and appendicular commands cranial nerves perrl brisk vf full eomi no nystagmus does endorse dizziness with extraocular movement testing v1 v3 without deficits to light touch bilaterally no facial movement asymmetry hearing intact to finger rub bilaterally palate elevation symmetric scm trapezius strength bilaterally tongue midline motor normal bulk and tone no drift no tremor or asterixis delt bic tri wre ffl fe io ip quad ham ta l r sensory paresthesias over bilateral palms to soft touch no exinction to dss dtrs bi tri pat ach l r plantar response flexor bilaterally coordination no dysmetria with finger to nose testing bilaterally gait wide based listing to the left assisted with a cane discharge physical exam endorses dizziness w eom to r otherwise non focal pertinent results 20am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00pm blood ptt 20am blood glucose urean creat na k cl hco3 angap 00pm blood glucose urean creat na k cl hco3 angap 00pm blood alt ast alkphos totbili 00pm blood lipase 25am blood calcium phos mg 05am blood calcium phos mg 00pm blood albumin 06pm blood hba1c eag 00pm blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg head w and w o unchanged nonenhancing white matter lesions as described in keeping with history of multiple sclerosis no new lesion or associated enhancement no acute intracranial abnormality including hemorrhage infarct or enhancing mass brief hospital course pt presented to per outpt neurologist due to acute worsening of chronic vertigo he underwent mri brain with no new ms lesions noted although due to concern for new flare was started on steroid therapy initially w solumedrol 1g for days despite no significant improvement pt was continued at lower dose of and then 250mg for more days with total administration of days during treatment with high dose steroid therapy patient was noted to have markedly elevated blood sugars with diabetes regimen adjusted by consult service with changes to his long acting and short acting insulin regimen patient s sugars improved following treatment with steroid therapy pt was also noted to have improvement in his vertiginous symptoms except for continued dizziness with certain eye movements due to his improvement and completion of steroid therapy patient was deemed stable for discharge from the hospital transition issues pt will need to continue monthly infusion and follow up with dr in near future pt will need to continue as outpt pt will need to adjust diabetes regimen as noted in discharge instructions with metformin 1000mg bid lantus units in morning and adjusted humalog sliding scale at mealtimes pt will need to follow up with for continued management of his diabetes medications on admission the preadmission medication list is accurate and complete tamsulosin mg po qhs amphetamine dextroamphetamine mg po daily prn adhd glargine units breakfast natalizumab mg ml injection monthly metformin glucophage mg po daily propranolol mg po bid lovastatin mg oral qhs aspirin mg po daily ondansetron mg po bid discharge medications glargine units breakfast insulin sc sliding scale using hum insulin rx insulin glargine lantus unit ml as dir units before bkft disp vial refills rx insulin lispro humalog kwikpen unit ml as dir up to units qid per sliding scale disp syringe refills metformin glucophage mg po bid rx metformin glucophage mg tablet s by mouth twice daily disp tablet refills amphetamine dextroamphetamine mg po daily prn adhd aspirin mg po daily lovastatin mg oral qhs propranolol mg po bid tamsulosin mg po qhs natalizumab mg ml injection monthly outpatient physical therapy discharge disposition home discharge diagnosis acute on chronic vertigo discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr you were hospitalized at for symptoms of chronic vertigo which had worsened recently initially there was concern that your worsening vertigo may have been due to a multiple sclerosis flare in this case the vertigo would be responsive to steroids you underwent brain mri which did not show evidence of new or active ms lesions since your last image you were treated with days of high dose steroids without significant improvement this makes it much less likely that a ms flare was the cause of your symptoms there are many causes of vertigo your doctors suspect your is playing a significant role in yours we recommend that you continue to follow with to better control your sugars please continue diabetes regimen as discussed with units glargine in am metformin 1000mg bid and sliding scale as provided please follow up with dr as noted below it was a pleasure taking care of you your care team followup instructions

name unit no admission date discharge date date of birth sex f service orthopaedics allergies no known allergies adverse drug reactions attending complaint right knee pain major surgical or invasive procedure right total knee replacement rg md history of present illness w r knee oa who presents for right total knee replacement past medical history hypertension obesity social history family history noncontributory 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 staples scant serosanguinous drainage thigh full but soft no calf tenderness strength silt nvi distally toes warm pertinent results x rays of the right knee obtained post op showed a right total knee replacement in good alignment without fracture 14am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 55am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 56am blood ret aut abs ret 14am blood glucose urean creat na k cl hco3 angap 56am blood ld ldh totbili 14am blood calcium phos mg 56am blood caltibc ferritn trf brief hospital course the patient was admitted to the orthopedic 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 on pod overnight the patient was given ml of fluids for low urine output on pod the patient s temperature spiked to urines were sent she was suspected to have a urinary tract infection and started on cipofloxacin on pod the patient was intermittently febrile and requiring oxygen nc a chest xray was performed and marginal for rll pneumonia on pod ms continued to have a fever to her urine culture was found to be negative a cbc diff and sputum culture were sent and her antibiotic course was changed to cover pna levaquin 750mg po qd x days a 500cc fluid bolus was given for mild hypotension pod remained afebrile with stable vitals continued levaquin per med recs otherwise pain was controlled with a combination of iv and oral pain medications the patient received lovenox for dvt prophylaxis starting on the morning of pod the foley was removed and the patient was voiding independently thereafter the surgical dressing was changed and the silverlon dressing was removed on pod the surgical incision was found to be clean and intact without erythema or abnormal drainage the patient was seen daily by physical therapy labs were checked throughout the hospital course and repleted accordingly drain was removed once output slowed down 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 and the wound was benign the patient s weight bearing status is weight bearing as tolerated on the operative extremity ms is discharged to rehab in stable condition medications on admission the preadmission medication list is accurate and complete amlodipine mg po daily pregabalin mg po tid tramadol mg po q6h prn severe lbp ibuprofen mg po q8h prn pain oxybutynin chloride mg oral daily discharge medications amlodipine mg po daily pregabalin mg po tid acetaminophen mg po q8h docusate sodium mg po bid rx docusate sodium mg capsule s by mouth twice a day disp capsule refills enoxaparin sodium mg sc daily rx enoxaparin mg ml mg sc daily disp syringe refills oxycodone immediate release mg po q4h prn pain rx oxycodone mg tablet s by mouth every hours disp tablet refills oxybutynin chloride mg oral daily levofloxacin mg po daily duration days discharge disposition extended care facility discharge diagnosis right knee osteoarthritis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions please 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 shaking chills increasing redness or drainage from the incision site chest pain shortness of breath or any other concerns please follow up with your primary physician regarding this admission and any new medications and refills resume your home medications unless otherwise instructed 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 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 days if you would like your medication mailed to your home you may not drive a car until cleared to do so by your surgeon please call your surgeon s office to schedule or confirm your follow up appointment in three weeks swelling ice the operative joint 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 please do not take any non steroidal anti inflammatory medications nsaids such as celebrex ibuprofen advil aleve motrin naproxen etc anticoagulation please continue your lovenox for four weeks to help prevent deep vein thrombosis blood clots if you were taking aspirin prior to your surgery it is ok to continue at your previous dose while taking this medication wound care please keep your incision clean and dry it is okay to shower five days after surgery but no tub baths swimming or submerging your incision until after your four week checkup please place a dry sterile dressing on the wound each day if there is drainage otherwise leave it open to air check wound regularly for signs of infection such as redness or thick yellow drainage staples will be removed by your doctor at follow up appointment approximately weeks after surgery once at home home dressing changes as instructed and wound checks activity weight bearing as tolerated on the operative extremity mobilize with assistive devices if needed range of motion at the knee as tolerated no strenuous exercise or heavy lifting until follow up appointment followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies fentanyl zantac flagyl entocort ec sulfa sulfonamide antibiotics attending chief complaint abdominal pain major surgical or invasive procedure flex sigmoidoscopy history of present illness history of present illness female patient with a history of disease restarted on humira for new flare who came to the ed for abdominal pain since the morning of concerning for acute on chronic flare found to have colitis on ct and leukocytosis to and admitted for workup and iv antibiotics per her report she was diagnosed with hemorrhagic in her and nothing initially could control the bleeding she required a partial resection she eventually went into a admission developing abdominal pain and cramping in she was initially diagnosed with diverticulitis but on ct scan was found to have colitis she had a day admission to at this time for abdominal pain and symptomatic hypotension at the end of she underwent a colonoscopy which showed chronic severely active colitis with ulceration which was negative for cmv she was started on humira the beginning of the morning of admission she woke up feeling lightheaded and was dizzy on standing and knew that her blood pressure was low she also had cramping abdominal pain her last bowel movement was days prior to admission and was a formed stool she has been unable to tolerate p o for the past several days she has had some nausea and reflux as well these are more chronic symptoms for she feels fatigued and weak in the ed initial vs were nasal cannula she triggered for hypotension and was given first 1l ns with improvement to she received l normal saline at g vancomycin at 5g pip tazo at 1g apap po at subsequent pressures were prompting the additional ns mentioned above past medical history on humira reflux with dysphagia hiatal hernia diverticulitis bronchiectasis positive hepatitis c antibody with a negative hcv rna history of a sleep disorder pruritus fibroid uterus sjogren s syndrome clinical negative autoantibody testing interstitial cystitis fibromyalgia and chronic social history family history grandmother and several great aunts had disease father with type diabetes brother passed away from aml in his physical exam admission physical exam vs ra general nad thin but not cachectic appears elderly and mildly diaphoretic but nontoxic heent perrl dry mucous membranes neck full rom no lad heart rrr s1 s2 no murmurs gallops or rubs lungs ctab no wheezes rales rhonchi breathing comfortably without use of accessory muscles abdomen well healed rlq scar minimally distended tender to palpation throughout worse in llq no rebound guarding hyperactive bowel sounds typmpanic to percussion extremities wwp no cyanosis clubbing or edema pulses dp pulses bilaterally neuro a ox3 face grossly symmetric no dysarthria moving all extremities with purpose skin no excoriations or lesions no rashes discharge physical exam physical exam vs po nl lying rr o292 ra general nad awake alert heent at nc eomi perrl anicteric sclera cracked lips mmm heart rrr normal s1 s2 no murmurs gallops or rubs lungs clear to auscultation no increased work of breathing no crackles abdomen soft nd nt no rebound guarding midline scar from remote surgery normoactive hypoactive bowel sounds improved extremities no edema neuro a ox3 ambulating normal skin warm and well perfused pertinent results admission labs 30pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30pm blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 30pm blood plt 30pm blood glucose urean creat na k cl hco3 angap 30pm blood alt ast alkphos totbili 30pm blood albumin 30pm blood crp 10pm blood po2 pco2 ph caltco2 base xs 10pm blood lactate 45am blood crp 30pm blood crp discharge labs 40am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 40am blood plt 40am blood glucose urean creat na k cl hco3 angap 20am blood alt ast alkphos totbili 40am blood calcium phos mg 25am blood vitb12 folate 25am blood crp microbiology stoolc difficile dna amplification assay negative urine urine culture negative blood cultureblood culture negative blood cultureblood culture negative stoolfecal culture negative culture negative culture negative culture negative imaging lung cta no pulmonary embolism or acute aortic abnormality acute on chronic flare with thickened hyperemic transverse and descending colon no definite bowel obstruction large left upper pole renal cyst with septations may be further assessed with non emergent renal ultrasound fibroid uterus two lung nodules measuring up to mm along the left fissure cxr cardiac silhouette size is normal mediastinal and hilar contours are unremarkable the pulmonary vasculature is not engorged elevation of the right hemidiaphragm is of indeterminate chronicity patchy opacities within the lung bases likely reflect areas of atelectasis no pleural effusion or focal consolidation is noted there are no acute osseous abnormalities no subdiaphragmatic free air is present colonic and small bowel dilatation likely ileus consider cross sectional imaging if there is concern for obstruction chest xray left basal peribronchial opacification is improved slightly right hemidiaphragm remains severely elevated and is responsible for new right middle lobe atelectasis upper lungs are clear heart size is normal pleural effusions small if any no pneumothorax abd xray no significant change in bowel distention from the exam done two days ago no free air demonstrated echo 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 there is mild symmetric left ventricular hypertrophy the left ventricular cavity size is normal left ventricular systolic function is hyperdynamic ef tissue doppler imaging suggests a normal left ventricular filling pressure pcwp 12mmhg the right ventricular free wall thickness is normal right ventricular chamber size is normal with normal free wall contractility the diameters of aorta at the sinus ascending and arch levels are normal the aortic valve leaflets appear structurally normal with good leaflet excursion there is no aortic valve stenosis mild aortic regurgitation is seen the mitral valve appears structurally normal with trivial mitral regurgitation the left ventricular inflow pattern suggests impaired relaxation there is borderline pulmonary artery systolic hypertension there is no pericardial effusion cxr no significant interval change since the prior chest radiograph no evidence of pulmonary edema ct abd pelvis no evidence of intra abdominal abscess interval increased conspicuity of right hepatic lobe wedge shaped perfusion abnormality likely representing evolving infarct moderate colonic stool consider constipation mildly increased size of left renal cyst with thin enhancing septations measuring cm previously measured cm additional findings as above liver mri previously seen abnormality at dome of the liver is not visualized on mri the liver enhances homogeneously and there is no evidence of focal mass or infarction brief hospital course brief hospital course female patient with a history of disease restarted on for new flare who came to the ed for abdominal pain since the morning of concerning for acute on chronic flare found to have colitis on ct and leukocytosis to and admitted for workup and iv antibiotics gi was consulted and followed the patient throughout the hospitalization it was believed the abdominal pain came about secondary to constipation and abdominal distention the patient was given an aggressive bowel regimen which helped the symptoms which we believe were secondary to a previous botox injection for pelvic floor disfunction the patient also received her second loading dose of humira while in the hospital and was started on a course of steroids initially iv to po prednisone her abdominal pain and distension continued to improve and was at baseline at discharge throughout the hospitalization the patient also had continued hypoxia which was something she had experienced at a recent hospitalization at but without any clear reason the patient required of oxygen for the first half of her stay to remain in the low on her o2 stat and would desat into the high and low during ambulation outside records could not be gathered regarding any hypoxia it was believe this was caused by a raised right hemidiaphragm causing low lung volumes atlectosis from laying in bed and blunting secondary to abdominal pain the patient was also found to have a pneumonia cap which was treated for days with levaquin ultimately once the patient began ambulating and her abdominal pain improved she was able to come of all o2 without difficulty and did not require home oxygen the patient was also found to have leukocytosis on admission which reached a nadir of during the middle of the hospitalization when the patient felt well however began to rise without a clear cause the wbc went up to and stabilized around this value and although the patient had been started on steroids was a suspicious rise in the context of her clinical picture a blood smear was obtained which showed inflammation b12 deficiency and some questionable mds type cells the patients b12 was found to be low at but an mma was not obtained as it an outpatient lab to evaluate for other potential causes of leukocytosis a ct abdomin pelvis was done to evaluate for potential abscess occult infection and revealed a wedge shaped infarct in a peripheral region of her liver to further classify this and to look for any local process which could have contributed a mri liver was done which did not demonstrate the lesion and heme onc did not recommend anticoagulation the patient was discharged home in stable condition transitional issues check cbc in week to evaluate improving leukocytosis if continues to be elevated consider heme onc referral for possible bone marrow biopsy for mds vitamin b12 was deficient will replete b12 and folate consider follow up with methylmalonic acid and or homocysteine levels patient had severe constipation and on numerous anticholinergeric medications can consider modifying her regimen cholestyramine was held due to constipation can consider restarting if diarrhea reoccurs patient s blood pressure had dizziness when taking lisinopril this was held during hospitalization and not restarted on d c can consider restarting as outpatient medications new meds prednisone 50mg daily tapering 10mg weekly on until 30mg daily stopped meds sodium chloride tablets lisinopril changed meds none incidental findings renal cyst large left upper pole renal cyst on ct again on ct abd pelvis with septations will need follow up in year with renal ultrasound pulm nodules mm left fissural nodule and mm rml nodule on ct for incidentally detected multiple solid pulmonary nodules 6mm no ct follow up is recommended in a low risk patient optional ct follow up in months is recommended in a high risk patient can consider f u ct in months contact code full code active colitis crohns abdominal pain was consistent with acute on chronic crohns flare ruled out infectious colitis w neg c diff and stool cultures kub demonstrated dilated colon with potential ileus was given a strong bowel regimen started on steroids and patient had humira loading dose on a flex sig unremarkable to sigmoid though unable to visualize much due to poor prep gi followed closely and recommended tapering steroids weekly by 10mg starting on eventually continuing at 30mg po daily until follow up with in outpatient leukocytosis wedge shaped low attentuation found on ct a p which was suspicious for a liver infarct was originally thought to be cause of leukocytosis however was not redemonstrated on mri at discharge the is will follow up with pcp week and consider heme onc referral for further evaluation possible bone marrow biopsy and consideration of mds constipation improving bowel function on bowel regimen daily suppositories colace senna constipation rectal sphincter dysfunction from hx of botox injections for pelvic floor dysfunction also precipitated by inflammation from active crohns flare on numerous medications which can contribute but did not want to change regimen at this time her cholestyramine was held during hospitalization hypoxia resolving o2sat in low on ra throughout hospitalization hypoxia likely secondary to splinting atelectasis and poor lung expansion precipitated by pna and completed a day levo unclear hx of preload failure but tte without shunt or evidence of right heart strain vbg appropriate on ct negative for pe on admission pulm consult suggesting atelectasis as cause appreciate recs patient was recommended to follow up outpatient with pulmonologist dr at and sleep doctor at b12 deficiency b12 low at no hyper segmentation seen on smear currently asymptomatic with no gi or neuro sxs heme onc recommended to get an mma and start b12 injections these were not done in house as it is a send out lab chronic hypertension home lisinopril was held pots has episodes of dizziness a w abdominal pain holding home salt tablets can continue outpatient sjogren s vaginal dryness pelvic floor dysfunction misc home eye drops home vaginal diazepam bid home doxepin hs hold home fluconazole unless having symptomatic yeast infection home pregabalin tid home prevalite home carisoprodol medications on admission the preadmission medication list is accurate and complete ondansetron mg po q8h prn nausea humira adalimumab unknown subcutaneous unknown pantoprazole mg po q24h carisoprodol mg oral tid prn doxepin hcl mg po hs lisinopril mg po daily prevalite cholestyramine aspartame gram oral bid diazepam mg po q12h pelvic floor dysfunction dronabinol mg po bid tid prn nausea sodium chloride dose is unknown po tid pregabalin mg po tid fluconazole mg po q24h discharge medications artificial tears preserv free drop both eyes prn dry eyes bisacodyl aily cyanocobalamin mcg im sc daily duration days rx cyanocobalamin vitamin b vitamin b mcg ml mcg im weekly disp vial refills docusate sodium mg po bid folic acid mg po daily prednisone mg po daily rx prednisone mg tablet s by mouth daily disp tablet refills senna mg po bid prn constipation sucralfate gm po qid prn stomach pain humira adalimumab mg subcutaneous 1x week carisoprodol mg oral tid prn diazepam mg po q12h pelvic floor dysfunction doxepin hcl mg po hs dronabinol mg po bid tid prn nausea fluconazole mg po q24h ondansetron mg po q8h prn nausea pantoprazole mg po q24h pregabalin mg po tid held lisinopril mg po daily this medication was held do not restart lisinopril until you see your pcp held prevalite cholestyramine aspartame gram oral bid this medication was held do not restart prevalite until you talk to your pcp or gi doctor because you were constipated in the hospital held sodium chloride dose is unknown po tid this medication was held do not restart sodium chloride until you talk to your pcp discharge disposition home with service facility discharge diagnosis primary flare secondary pneumonia vitamin b12 deficiency discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms you came to because you were having abdominal pain and bloating in your stomach you were found to have a flare of your disease and a pneumonia you were given antibiotics for your infections and started on steroids the gastrointestinal gi team came to see you and you got your second loading dose of humira you were having low oxygen numbers and were found to have a pneumonia and were treated with antibiotics you were seen by a hematologist a doctor who is an expert in blood problems who found you had low vitamin b12 you also had a ct scan which showed a possible area of low blood flow in your liver but another imaging test an mri was done to help us look at this and did not find anything abnormal please see the instructions for what to do after leaving the hospital you should continue your prednisone mg until and then decrease your dose by 10mg every until you are taking 30mg a day and follow up with dr you should follow up with you pcp on you should start weekly humira administration on with the next dose you should take your b12 shot once a week you should talk to your gi doctor about your cholestyramine you should talk to your pcp about your sodium chloride pills it was a pleasure participating in your care we wish you the best sincerely your care team followup instructions

name unit no admission date discharge date date of birth sex f service surgery allergies tetracycline attending chief complaint pancreatic cancer major surgical or invasive procedure exploratory laparoscopy radical pancreaticoduodenectomy with distal gastrectomy en bloc resection of main portal vein and replace right hepatic artery cholecystectomy end to end primary repair of portal vein placement of gold fiducials end to side duct to mucosa pancreaticojejunostomy end to side hepaticojejunostomy antecolic gastrojejunostomy transgastric feeding jejunostomy history of present illness mrs is a woman who has completed preoperative chemotherapy and radiation for borderline resectable pancreatic ductal carcinoma characterized by main portal vein involvement and encasement of the very large replaced right hepatic artery she has completed chemoradiation as well as preoperative plugged occlusion of the replaced right hepatic artery with development of adequate arterial collaterals to the right liver she is now taken to the operating room for definitive surgical resection and vascular reconstruction the risks and benefits of surgery have been discussed with the patient in great detail and are documented in a separate note past medical history hypothyroidism s depression hyperlipidema although not on statin currently nephrolithiasis long time ago passed a kidney stone past surgical history prior eye surgery many years ago to correct a strabismus when she was a child social history family history she notes that her mother had an episode of jaundice at or years was diagnosed with colon cancer at age and died months later grandmother died from septicemia abdominal causes she is of five children all in good health sister with disease physical exam prior to discharge vs ra gen nad cv rrr no m r g pulm ctab abd trapdoor incision open to air with steri strips and c d i rlq old jp sites with dsd and c d i extr warm no c c e pertinent results 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood glucose urean creat na k cl hco3 angap 11am blood alt ast alkphos totbili 00am blood calcium phos mg 44pm ascites amylase 45pm ascites amylase pathology pancreatic adenocarcinoma brief hospital course the patient with pancreatic ca s p neoadjuvant therapy was admitted to the hpb surgical service for elective whipple on the patient underwent pancreaticoduodenectomy whipple open cholecystectomy and portal vein reconstruction 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 with an ng tube on iv fluids with a foley catheter and a jp drain in place and epidural catheter for pain control the patient was hemodynamically stable the hospital course was uneventful and followed the clinical pathway without deviation post operative pain was initially well controlled with epidural and pca which was converted to oral pain medication when tolerating clear liquids the ng tube was discontinued on pod and the foley catheter discontinued at midnight of pod the patient subsequently voided without problem the patient was started on sips of clears on pod which was progressively advanced as tolerated to a regular diet by pod jp amylase was sent in the evening of pod the jp was discontinued on pod as the output and amylase level were low during this hospitalization the patient ambulated early and frequently was adherent with respiratory toilet and incentive spirrometry and actively participated in the plan of care the patient received subcutaneous heparin and venodyne boots were used during this stay the patient s blood sugar was monitored regularly throughout the stay sliding scale insulin was administered when indicated at the time of discharge on 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 staples were removed and steri strips placed the patient was discharged home without services the patient received discharge teaching and follow up instructions with understanding verbalized and agreement with the discharge plan medications on admission the preadmission medication list is accurate and complete venlafaxine mg po daily levothyroxine sodium mcg po daily creon cap po tid w meals lorazepam mg po q6h prn anxiety prochlorperazine mg po q6h prn nausea docusate sodium mg po bid loratadine mg po daily multivitamins tab po daily fish oil omega mg po daily polyethylene glycol g po daily discharge medications docusate sodium mg po bid levothyroxine sodium mcg po daily lorazepam mg po q6h prn anxiety venlafaxine xr mg po daily acetaminophen mg po q8h do not exceed more then mg day aspirin mg po daily rx aspirin mg tablet s by mouth once a day disp tablet refills hydromorphone dilaudid mg po q4h prn pain rx hydromorphone mg tablet s by mouth every four hours disp tablet refills metoclopramide mg po qidachs rx metoclopramide hcl mg tab by mouth qidachs disp tablet refills oxycodone sr oxycontin mg po q12h pantoprazole mg po q12h rx pantoprazole mg tablet s by mouth every twelve hours disp tablet refills senna mg po bid fish oil omega mg po daily loratadine mg po daily multivitamins tab po daily polyethylene glycol g po daily prochlorperazine mg po q6h prn nausea ondansetron odt mg po q8h prn nausea rx ondansetron zofran odt mg tablet s by mouth every eight hours disp tablet refills creon cap po tid w meals enoxaparin sodium mg sc daily start today first dose next routine administration time discharge disposition home with service facility discharge diagnosis pancreatic adenocarcinoma discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted to the surgery service at for surgical resection of your pancreatic mass you have done well in the post operative period and are now safe to return home to complete your recovery with the following instructions please call dr office at or rn at if you have any questions or concerns please resume all regular home medications unless specifically advised not to take a particular medication also please take any new medications as prescribed please get plenty of rest continue to ambulate several times per day and drink adequate amounts of fluids avoid lifting weights greater than lbs until you follow up with your surgeon who will instruct you further regarding activity restrictions avoid driving or operating heavy machinery while taking pain medications please follow up with your surgeon and primary care provider pcp as advised incision care please call your doctor or nurse practitioner if you have increased pain swelling redness or drainage from the incision site avoid swimming and baths until your follow up appointment you may shower and wash surgical incisions with a mild soap and warm water gently pat the area dry if you have steri strips they will fall off on their own please remove any remaining strips days after surgery g j tube capped followup instructions

name unit no admission date discharge date date of birth sex f service surgery allergies tetracycline attending chief complaint inability to take po dehydration major surgical or invasive procedure none history of present illness the patient is a hx pancreatic adenoca s p radical whipple with pv reconstruction admitted for dehydration diarrhea and vomiting patient was discharged from the hospital on and did well for several days until days ago when she started experiencing nausea nbnb vomiting and inability to tolerate po intake with orthostatic dizziness reports associated crampy abdominal pain in the lower quadrants and frequent non watery small bowel movements mucus like in quality as well as chills but no fevers has noted a lb weight loss since discharge though has recently increased her synthroid dose from to and also reports occasional palpitations patient reports that she has stopped taking her po medications over since onset of symptomts patient was seen in clinic last week for drainage at the proximal aspect of her midline incision reports improvement in drainage though still persistent has not noted increased drainage or change in quality of drainage pain or redness at the site past medical history hypothyroidism s depression hyperlipidema although not on statin currently nephrolithiasis long time ago passed a kidney stone past surgical history prior eye surgery many years ago to correct a strabismus when she was a child social history family history she notes that her mother had an episode of jaundice at or years was diagnosed with colon cancer at age and died months later grandmother died from septicemia abdominal causes she is of five children all in good health sister with disease physical exam t bp hr95 ra rr general pale appearing female nad heent ncat sclera anicteric cardiac rrr no murmurs chest ctab normal work of breathing abd soft tender in lower abdomen non distended proximal aspect of midline incision open with minimal purulent drainage covered with bandage remainder of incision c d i g j tube site c d i ext wwp no edema skin no jaundice rashes pertinent results 20am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 20am blood glucose urean creat na k cl hco3 angap 20am blood calcium phos mg 30am blood albumin calcium phos mg 30am blood tsh 30am blood free t4 kub impression nonobstructive bowel gas pattern with large amount of stool in the descending and sigmoid colon and rectum mesenteric calcification as seen on prior exam still present micro 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 brief hospital course the patient s p classic whipple procedure with pv reconstruction on was admitted to the hpb surgical service from clinic for initiation of supplemental nutrition secondary to poor po intake at home and weight loss patient was started on iv fluid and tube feeds vital and nutritional service was consulted rd recommended continue tubefeed cc hr x hrs and cycle with rate cc hr x hrs when patient able on admission labs was noticed that patient has elevated tsh endocrinology service was consulted and patient s home dose synthroid was increased to mcg day from mcg day patient s tubefeed was slowly advanced to goal within next days secondary to poor tubefeed tolerance patient home dose creon was increased to with meals diet was advanced to fulls with supplements and was well tolerated on hd patient s tf was at goal an attempt to cycle tf over hours was taken patient only was able to tolerate tf at cc hr she was discharged home next day on regular diet and with order to continue tf at home with close to goal rate and advance to goal as tolerated patient s stool was negative for infection or parasites patient was started on hyoscyamine secondary to abdominal spasms at the time of discharge the patient was doing well afebrile with stable vital signs the patient was tolerating a regular diet and tubefeed with close to goal rate 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 docusate sodium mg po bid levothyroxine sodium mcg po daily lorazepam mg po q6h prn anxiety venlafaxine xr mg po daily acetaminophen mg po q8h do not exceed more then mg day aspirin mg po daily rx aspirin mg tablet s by mouth once a day disp tablet refills hydromorphone dilaudid mg po q4h prn pain rx hydromorphone mg tablet s by mouth every four hours disp tablet refills metoclopramide mg po qidachs rx metoclopramide hcl mg tab by mouth qidachs disp tablet refills oxycodone sr oxycontin mg po q12h pantoprazole mg po q12h rx pantoprazole mg tablet s by mouth every twelve hours disp tablet refills senna mg po bid fish oil omega mg po daily loratadine mg po daily multivitamins tab po daily polyethylene glycol g po daily prochlorperazine mg po q6h prn nausea ondansetron odt mg po q8h prn nausea rx ondansetron zofran odt mg tablet s by mouth every eight hours disp tablet refills creon cap po tid w meals enoxaparin sodium mg sc daily start today first dose next routine administration time discharge medications creon lipase protease amylase unit oral other take caps with meals and one cap with snacks rx lipase protease amylase creon unit unit unit capsule s by mouth qidachs disp capsule refills hyoscyamine mg po qid rx hyoscyamine sulfate mg tablet s by mouth four times a day disp tablet refills loperamide mg po qid prn diarrhea rx loperamide mg capsule s by mouth four times a day disp capsule refills psyllium wafer waf po daily for diarrhea vital cal nut tx impaired dige fxn fiber gram kcal ml oral daily tubefeed rate cc hr cycle for hours flush j tube with cc of h2o q8h rx nut tx impaired dige fxn fiber vital cal gram kcal ml mls j tube once a day refills levothyroxine sodium mcg po daily rx levothyroxine mcg tablet s by mouth once a day disp tablet refills acetaminophen mg po q6h prn pain mild aspirin mg po daily enoxaparin sodium mg sc daily start today first dose next routine administration time hydromorphone dilaudid mg po q4h prn pain severe rx hydromorphone mg tablet s by mouth every six hours disp tablet refills ondansetron mg po q8h prn nausea pantoprazole mg po q12h rx pantoprazole mg tablet s by mouth every twelve hours disp tablet refills venlafaxine xr mg po qhs discharge disposition home with service facility discharge diagnosis pancreatic ductal adenocarcinoma s p on dehydration severe malnutrition hyperthyroidism discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted to the surgery service at from clinic secondary to dehydration and poor po intake you were started on tubefeed pancreatic enzymes and continued on regular diet with supplements you and are now safe to return home to complete your recovery with the following instructions please call dr office at if you have any questions or concerns please resume all regular home medications unless specifically advised not to take a particular medication also please take any new medications as prescribed please get plenty of rest continue to ambulate several times per day and drink adequate amounts of fluids avoid lifting weights greater than lbs until you follow up with your surgeon who will instruct you further regarding activity restrictions avoid driving or operating heavy machinery while taking pain medications please follow up with your surgeon and primary care provider pcp as advised incision care nurses continue to change your wound dressing daily please call your doctor or nurse practitioner if you have increased pain swelling redness or drainage from the incision site avoid swimming and baths until your follow up appointment you may shower and wash surgical incisions with a mild soap and warm water gently pat the area dry g j tube keep g tube capped j tube flush with cc of tap water q8h before and after every use change dressing daily and prn monitor for signs and symptoms of infection prevent dislocation followup instructions