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name unit no admission date discharge date date of birth sex f service medicine allergies tetracycline attending chief complaint sepsis major surgical or invasive procedure none this hospitalization history of present illness is a yo woman with metastatic lung recurrence of stage ia ypt1n0m0 pdac pancreatic ca s p neoadjuvant folfirinox sbrt whipple adjuvant folfox on phase df trial who presents with fever and found to have gnr bacteremia and e coli uti she was feeling well until days pta when she felt feverish and spiked a temperature to tmax 3f she presented to the next morning and received infectious workup including bcx ucx flu strep cxr which were preliminarily negative she was discharged home but called back in late in the evening when bcx turned positive for gnrs at p she received a ct a p which did not show any intraabdominal source of infection ucx at that time was no growth but later it turned positive for cfu e coli she was started on zosyn and transferred to for further management in the ed t f ra she received iv zosyn prior to admission when seen at bedside mrs reports a frontal and posterior headache which she attributes to fatigue and says has been intermittent since the initiation of chemotherapy she also has some mild back and chest pain which she gets routinely after g csf received neulasta yesterday she also reports she has some abdominal discomfort and had loose bowel movement per day over the last days she otherwise denies n v recurrent fever chills sweats dysuria cloudy urine cough cold symptoms has chronic congestion for months but no sore throat rhinorrhea no sick contacts no suspicious food intake all other review of systems are negative unless stated otherwise past medical history metastatic recurrence of pancreatic cancer presented with transaminitis and malignant cbd stricture cta showed cm pancreatic head mass she received cycles of neoadjuvant folfirinox followed by sbrt and then whipple her final pathologic staging was t1n0 cm pdac in head of pancreas nodes negative margins pni and grade ii large vessel angiolymphatic invasion she received cycles of adjuvant folfox in ct torso showed multiple subcm pulmonary nodules which were noted to increase on follow up cts and a lung biopsy confirmed metastatic disease and she was consented and started on phase open label trial of rx in combination with abraxane at c1d1 hyperlipidemia hypothyroidism gerd depression nephrolithiasis remote eye surgery to correct strabismus she had when she was a child hx right breast alh s p excision at osh dry eyes dry mouth since chemotherapy 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 admission physical exam vitals t f ra general well appearing pleasant caucasian woman sitting up in bed neuro alert oriented to person place and time provides clear and cogent history heent oropharynx clear mmm no palpable cervical or supraclavicular adenopathy no sinus tenderness to palpation cardiovascular rrr soft systolic murmur chest pulmonary clear to auscultation bilaterally abdomen soft nontender nondistended bowel sounds present back no cva tenderness extr msk no peripheral edema skin no rashes on torso arms legs access r poc is c d i and nontender to palpation discharge physical exam vs temp bp hr rr o2 sat ra exam otherwise unchanged pertinent results admission labs 00pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00pm blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 56pm blood glucose urean creat na k cl hco3 angap 31am blood alt ast alkphos totbili discharge labs 31am blood calcium phos mg 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood glucose urean creat na k cl hco3 angap microbiology group a strep throat at rapid antigen negative culture pending influenza a b pcr at negative blood culture x at klebsiella pneumoniae urine culture at e coli blood culture x at pending influenza a b pcr negative urine culture pending blood culture x pending imaging cxr at impression unchanged and no evidence of active disease ct abdomen pelvis w contrast at impression bilateral pulmonary nodules are noted for which follow up chest ct is recommended to evaluate for stability no acute abdominal pelvic process is identified brief hospital course ms is a woman with metastatic pancreatic cancer s p neoadjuvant folfirinox sbrt whipple adjuvant folfox and currently on phase df trial who presents with fever and found to have gnr bacteremia and e coli uti sepsis secondary to klebsiella bacteremia culture data from of blood cultures growing klebsiella potentially transient bacteremia from biliary source received ct a p at which did not show intraabdominal abscess her cultures cleared and she was feeling well she had some mild diarrhea that was negative for c diff she was discharged to complete a day course of ciprofloxacin day to be completed e coli uti urine growing e coli but patient asymptomatic and ua unimpressive likely asymptomatic bacteriuria but regardless will be treated by cipro as above metastatic pancreatic adenocarcinoma secondary neoplasm of lung currently on phase trial of rx oral cytidine analogue abraxane last received c3d8 on she received neulasta at on continued home creon ativan and zofran will follow up in clinic anemia secondary to malignancy and chemotherapy leukocytosis likely secondary to neulasta which she receiving at no elevated wbc on initial presentation hlp continued home colesevelam hypothyroidism continued home levothyroxine gerd continued home omeprazole depression continued home venlafaxine billing minutes were spent in preparation of discharge summary and coordination with outpatient providers transitional issues patient discharged to complete a day course of ciprofloxacin day to be completed please follow up pending blood cultures from on please follow up multiple pending blood cultures from on medications on admission the preadmission medication list is accurate and complete colesevelam mg oral bid levothyroxine sodium mcg po daily lorazepam mg po q8h prn anxiety nausea omeprazole mg po daily ondansetron odt mg po q8h prn nausea vomiting first line venlafaxine xr mg po dinner vitamin d unit po daily coenzyme q10 mg oral daily docusate sodium mg po bid prn constipation first line senna mg po bid prn constipation first line multivitamins tab po daily fish oil omega mg po daily turmeric capsule oral daily creon lipase protease amylase unit oral tid w meals discharge medications ciprofloxacin hcl mg po q12h plan for day course day to be completed rx ciprofloxacin hcl mg take tablet by mouth twice daily disp tablet refills coenzyme q10 mg oral daily colesevelam mg oral bid creon lipase protease amylase unit oral tid w meals docusate sodium mg po bid prn constipation first line fish oil omega mg po daily levothyroxine sodium mcg po daily lorazepam mg po q8h prn anxiety nausea multivitamins tab po daily omeprazole mg po daily ondansetron odt mg po q8h prn nausea vomiting first line senna mg po bid prn constipation first line turmeric capsule oral daily venlafaxine xr mg po dinner vitamin d unit po daily discharge disposition home discharge diagnosis primary diagnosis sepsis secondary to klebsiella bacteremia e coli urinary tract infection metastatic pancreatic adenocarcinoma secondary neoplasm of lung anemia leukocytosis 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 the you were admitted to the hospital with a fever you were found to have a bacteria in your blood called klebsiella fortunately this bacteria can be treated with multiple antibiotics including oral antibiotics also only one of the blood cultures grew bacteria and the rest have remained negative you were discharged on ciprofloxacin to complete a week course you can start taking the antibiotic on morning you also had a cat scan of your abdomen and a chest x ray at that did now show any cause of the infection please continue your prior home medications please follow up with your outpatient team all the best your team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies tetracycline attending chief complaint fever major surgical or invasive procedure none history of present illness oncology hospitalist admission note date primary oncologist md primary diagnosis metastatic recurrence of pancreatic cancer treatment regimen rexahn trial df trial phase open label study of rx oral cytidine analogue abraxane hpi chief complaint fever is a yo woman with metastatic lung recurrence of stage ia ypt1n0m0 pdac pancreatic ca s p neoadjuvant folfirinox sbrt whipple adjuvant folfox on phase df trial discharged this afternoon for klebsiella bacteremia and e coli uti who returns to the hospital with fever to mrs reports she felt a little clammy last night she did not have any recorded fevers in the hospital on the way home she began having shaking chills she checked her temperature when she arrived home and found she had a temp to tmax via forehead probe and f via oral thermometer she called her oncologist and was directly re admitted she reports in retrospect she is having some more sinus congestion and clear rhinorrhea she didn t ambulate much in the hospital but on returning home she noticed she was dyspneic after going up one flight of stairs which is unusual for her she does not have cough palpitations fevers edema she reported a few loose stools during the first day of admission and a c diff was negative she has not had any more loose stool but does have some vague and diffuse abdominal discomfort she thinks her urine looks a little darker but does not have dysuria or flank pain on arrival to the floor t f all other review of systems are negative unless stated otherwise past medical history metastatic recurrence of pancreatic cancer presented with transaminitis and malignant cbd stricture cta showed cm pancreatic head mass she received cycles of neoadjuvant folfirinox followed by sbrt and then whipple her final pathologic staging was t1n0 cm pdac in head of pancreas nodes negative margins pni and grade ii large vessel angiolymphatic invasion she received cycles of adjuvant folfox in ct torso showed multiple subcm pulmonary nodules which were noted to increase on follow up cts and a lung biopsy confirmed metastatic disease and she was consented and started on phase open label trial of rx in combination with abraxane at c1d1 hyperlipidemia hypothyroidism gerd depression nephrolithiasis remote eye surgery to correct strabismus she had when she was a child hx right breast alh s p excision at osh dry eyes dry mouth since chemotherapy 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 physical exam vital signs po l manual sitting ra general nad heent mmm no thrush no op lesions cv rr nl s1s2 no s3s4 no mrg pulm ctab respirations unlabored abd bs snt nd limbs no wwp skin no rashes on extremities neuro speech fluent strength grossly intact psych thought process logical linear future oriented access r chest port site intact w o erythema accessed and dressing c d i pertinent results 40am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 40am blood glucose urean creat na k cl hco3 angap 40am blood calcium phos mg brief hospital course imaging cxr at impression unchanged and no evidence of active disease ct abdomen pelvis w contrast at impression bilateral pulmonary nodules are noted for which follow up chest ct is recommended to evaluate for stability no acute abdominal pelvic process is identified cxr impresion right sided port a cath projects to the svc cardiomediastinal silhouette is stable there is no pleural effusion no pneumothorax is seen assessment and plan ms is a woman with metastatic pancreatic cancer s p neoadjuvant folfirinox sbrt whipple adjuvant folfox and currently on phase df hcc trial with a recent admission for fever found to have klebsiella bacteremia and e coli uti who represents with fever to found to have a uri sepsis secondary to klebsiella bacteremia fever dyspnea nasal congestion rhinorrhea diarrhea discharged on cipro for klebsiella bacteremia of positive blood cultures from potentially transient bacteremia from biliary source ct a p at bid p did not show intraabdominal abscess now with recurrent fever with upper respiratory symptoms and diarrhea dyspnea and or diarrhea may be related to viral process c diff negative differential also includes tumor fever and fever secondary to chemotherapy agents which patient has reported in the past her symptoms spontaneously resolved with supportive therapy without any adjustments to her antibiosis flu neg continue cipro to complete a day course day to be completed metastatic pancreatic adenocarcinoma secondary neoplasm of lung currently on phase trial of rx oral cytidine analogue abraxane last received c3d8 on she received neulasta at on continue home creon ativan and zofran prn f u onc in clinic anemia secondary to malignancy and chemotherapy leukocytosis likely secondary to neulasta hlp cont home colesevelam hypothyroidism continue home levothyroxine gerd continue home omeprazole depression continue home venlafaxine fen regular ppx heparin sc bid inpatient access poc code full code presumed communication patient emergency contact hcp husband dispo home w o services billing min spent coordinating care for discharge d o heme hospitalist medications on admission the preadmission medication list is accurate and complete colesevelam mg oral bid levothyroxine sodium mcg po daily lorazepam mg po q8h prn anxiety nausea multivitamins tab po daily omeprazole mg po daily ondansetron odt mg po q8h prn nausea vomiting first line senna mg po bid prn constipation first line venlafaxine xr mg po dinner vitamin d unit po daily coenzyme q10 mg oral daily creon lipase protease amylase unit oral tid w meals docusate sodium mg po bid prn constipation first line fish oil omega mg po daily turmeric capsule oral daily ciprofloxacin hcl mg po q12h discharge medications ciprofloxacin hcl mg po q12h last day coenzyme q10 mg oral daily colesevelam mg oral bid creon lipase protease amylase unit oral tid w meals docusate sodium mg po bid prn constipation first line fish oil omega mg po daily levothyroxine sodium mcg po daily lorazepam mg po q8h prn anxiety nausea multivitamins tab po daily omeprazole mg po daily ondansetron odt mg po q8h prn nausea vomiting first line senna mg po bid prn constipation first line turmeric capsule oral daily venlafaxine xr mg po dinner vitamin d unit po daily discharge disposition home discharge diagnosis viral upper respiratory infection discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear was a pleasure caring for you in the hospital you were admitted with a recurrent fever and found to have most likely a viral respiratory infection you had no evidence of pneumonia on x ray and your blood cultures and urine cultures from have not grown anything you need to continue your day course of ciprofloxacin day to be completed followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies tetracycline attending chief complaint fever major surgical or invasive procedure none history of present illness is a yo woman with metastatic lung recurrence of stage ia ypt1n0m0 pdac pancreatic ca s p neoadjuvant folfirinox sbrt whipple adjuvant folfox on phase df hcc trial who presents after c4d8 of chemotherapy with fever to f mrs was admitted twice early this month with fevers during her first admission she was found to have klebsiella bacteremia pansensitive possibly from gi source and e coli uti she was discharged but returned later that day with recurrent fever and uri symptoms she completed a day course of ciprofloxacin yesterday morning of chemotherapy she had lower abdominal cramps and loose bowel movement her stool was nonbloody and watery with small pieces she otherwise felt well and presented for c4d8 when she got home she called her oncologist with a fever initially her fever persisted over several hours with tmax 2f she also had further loose bowel movements that evening and presented to for evaluation at she had low grade temps to basic labs included wbc and normal bmp lfts she had a ruq us and cxr which were unrevealing she received ctx given prior culture data of pansensitive e coli and klebsiella and was transferred to in the ed here her tmax was 3f on arrival to floor mrs states she has a resolving tension headache which usually accompanies her fevers she does not currently feel feverish or chilled she denies nausea vomiting dysuria she reports resolving nasal congestion and dry cough since her uri symptoms first developed during her last admission her husband developed uri symptoms weeks ago after her presumed viral uri she denies suspicious food intake or other sick contacts past medical history hyperlipidemia hypothyroidism gerd depression nephrolithiasis remote eye surgery to correct strabismus she had when she was a child hx right breast alh s p excision at osh dry eyes dry mouth since chemotherapy metastatic recurrence of pancreatic cancer presented with transaminitis and malignant cbd stricture cta showed cm pancreatic head mass she received cycles of neoadjuvant folfirinox followed by sbrt and then whipple her final pathologic staging was t1n0 cm pdac in head of pancreas nodes negative margins pni and grade ii large vessel angiolymphatic invasion she received cycles of adjuvant folfox in ct torso showed multiple subcm pulmonary nodules which were noted to increase on follow up cts and a lung biopsy confirmed metastatic disease and she was consented and started on phase open label trial of rx in combination with abraxane at c1d1 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 general well appearing woman sitting in chair heent oropharynx clear mmm no lesions cv rrr no murmur pulm clear bilaterally to auscultation abd soft nontender nondistended normoactive bowel sounds limbs no peripheral edema wwp skin no rashes neuro alert oriented provides clear history access r poc is accessed and c d i pertinent results 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt tsh micro u a bland ucx no growth bcx x pending one from port one peripheral ngtd flu swab negative bcx x ngtd norovirus negative c diff pcr positive but toxin negative stool culture negative imaging ruq findings the liver is diffusely echogenic consistent with severe fatty infiltration the patient is status post cholecystectomy the common duct measures mm the right kidney measures cm the right renal cortex is preserved there is no hydronephrosis in the right kidney the pancreas is not seen due to bowel gas impression fatty infiltration of the liver cxr the heart is not enlarged the lungs are clear bilaterally with normal pulmonary vascular distribution there is no pleural fluid a right sided port a cath terminates in the distal superior vena cava impression no acute pulmonary infiltrates brief hospital course with metastatic lung recurrence of stage ia ypt1n0m0 pdac pancreatic ca s p neoadjuvant folfirinox sbrt adjuvant folfox on phase df trial who presents after c4d8 of chemotherapy with fever to f and episodes of loose stool fever diarrhea recently admitted for fever after chemotherapy and was found to have klebsiella bacteremia pansensitive possibly from gi source and e coli uti she completed treatment with ciprofloxacin on she presented to with fever to shortly after c4d8 of chemotherapy initial workup included ruq us and cxr which were unrevealing she was started on ceftriaxone to treat empirically for the previous klebsiella bacteremia stool studies were sent and her c diff pcr returned positive ceftriaxone was discontinued and po vancomycin was started however hours later her c diff toxin returned negative all antibiotics were held and she was observed for hours without recurrence of fever the rest of her infectious workup was negative as noted in the previous section this is mrs fever that has occurred after chemotherapy her case was discussed with her outpatient oncologist with the suspicion that her fevers are caused by her chemotherapy treatment she will see her oncologist in follow up the week after discharge for further recommendations outpatient plan for management of post chemotherapy fevers metastatic recurrence of stage ia pancreatic adenocarcinoma s p on phase trial of rx oral cytidine analogue abraxane s p suspicion that fever is in setting of chemotherapy as above her trial drug was held for this cycle due to concern for infection please note for future admissions that mrs home creon is 3x the strength of bi formulary creon she tolerated a regular diet in the hospital with creon capsules with meals and capsules with snacks hot flashes she reported hot flashes since initiation of chemotherapy a tsh was checked which returned normal after patient s discharge inform patient of normal tsh medications on admission the preadmission medication list is accurate and complete creon lipase protease amylase unit oral tid w meals levothyroxine sodium mcg po daily lorazepam mg po q8h prn anxiety nausea multivitamins tab po daily omeprazole mg po daily venlafaxine xr mg po dinner vitamin d unit po daily coenzyme q10 mg oral daily colesevelam mg oral bid docusate sodium mg po bid prn constipation first line fish oil omega mg po daily ondansetron odt mg po q8h prn nausea vomiting first line senna mg po bid prn constipation first line turmeric capsule oral daily discharge medications coenzyme q10 mg oral daily colesevelam mg oral bid creon lipase protease amylase unit oral tid w meals docusate sodium mg po bid prn constipation first line fish oil omega mg po daily levothyroxine sodium mcg po daily lorazepam mg po q8h prn anxiety nausea multivitamins tab po daily omeprazole mg po daily ondansetron odt mg po q8h prn nausea vomiting first line senna mg po bid prn constipation first line turmeric capsule oral daily venlafaxine xr mg po dinner vitamin d unit po daily discharge disposition home discharge diagnosis fever with negative infectious workup discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent md completed by

name unit no admission date discharge date date of birth sex f service medicine allergies tetracycline attending chief complaint fever major surgical or invasive procedure none history of present illness ms is a female with history of stage ia ypt1n0m0 pdac s p neoadjuvant folfirinox sbrt whipple adjuvant folfox now with metastatic disease to the lung on rexahn trial df trial who presents with fever the patient was admitted months ago with high grade fevers due to pan sensitive klebsiella bacteremia of unclear source since discharge the patient had been doing well but had continued to have low grade fevers which was attributed to her chemotherapy which improved with taking dexamethasone over the last week or so the patient had noticed increased fatigue and dizziness with persistently low grade fevers she contacted her outpatient oncologist who recommended she keep a close eye on her temperature the day prior to admission it spiked to in addition over the last few days she has had increased rhinorrhea and sinus congestion but states she has had milder versions of these symptoms throughout the winter in addition she has had a mild headache without vision changes furthermore over the last days she has had positional substernal chest pain which she described as throbbing it is constant without radiation and exacerbated with deep breaths and lying flat it is relieved with leaning forward it is not associated with dyspnea and is without radiation lastly over the last weeks she has had intermittent loose non bloody stool up to times per day days ago she took imodium which stopped her bms she has not have a bm since given her fever she presented to ed for further evaluation she initially presented to where vitals were temp bp hr rr and o2 sat ra labs were notable for wbc h h plt na k bun cr phos mg lfts lipase wnl lactate and ua negative blood cultures were sent cxr was negative cta chest was negative for pneumonia but remonstrated metastatic disease she was given zosyn tylenol ibuprofen and ns she was transferred to the ed on arrival to the ed initial vitals were ra exam was notable for stenal tenderness to palpation labs were notable for wbc h h plt na k and bun cr influenza a b pcr was negative ecg showed nsr with inferior q waves of note the patient was admitted with sepsis in due to pan sensitive klebseilla bacteremia without obvious source on arrival to the floor patient reports the above history and feels slightly more energized she has no fevers or chills chest pain as noted above no dyspnea or abd pain no dysuria past medical history pancreatic ca hyperlipidemia hypothyroidism gerd depression nephrolithiasis right breast alh in s p excision s p remote eye surgery to correct strabismus she had 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 gen well appearing pleasant caucasian woman sitting up in bed heent oropharynx clear mmm sclerae anicteric rrr no murmurs resp ctab abd soft nontender nondistended ext warm no peripheral edema skin dry no rashes neuro alert fluent speech answers questions appropriately perrl palate elevates symmetrically access poc c d i pertinent results pertinent labs blood culture x ngtd blood culture x ngtd rapid flu pcr negative respiratory viral screen inadequate sample pertinent imaging cxr at linear opacity in the left lower lobe likely due to linear atelectasis noted slightly enlarged heart right venous catheter in place cta chest at large irregular right lower lobe lesion with numerous nodules bilaterally no acute thoracic abnormality seen otherwise brief hospital course with metastatic pancreatic cancer and history of klebsiella bacteremia who presented from home with fevers to rhinorrhea congestion and substernal chest pain fevers presented with fever to with uri symptoms and suspected pericarditis substernal chest pain that was worse with lying flat and better with sitting forward given her previous history of klebsiella bacteremia and immunosuppression in the setting of chemotherapy she was started on broad spectrum antibiotics blood cultures were unrevealing and she had no further episodes of fever while hospitalized her antibiotics were peeled off and ultimately stopped on the morning of discharge ekg was unchanged from prior a tte was considered but her pericarditis symptoms self resolved with supportive care and was deferred metastatic pancreatic adenocarcinoma secondary neoplasm of lung currently on phase trial of rx oral cytidine analogue abraxane she will follow up tomorrow in clinic for continuation of therapy medications on admission the preadmission medication list is accurate and complete creon lipase protease amylase unit oral tid w meals levothyroxine sodium mcg po daily lorazepam mg po q8h prn anxiety nausea omeprazole mg po daily ondansetron odt mg po q8h prn nausea vomiting first line venlafaxine xr mg po dinner vitamin d unit po daily coenzyme q10 mg oral daily colesevelam mg oral bid turmeric capsule oral daily pyridoxine mg po daily discharge medications coenzyme q10 mg oral daily colesevelam mg oral bid creon lipase protease amylase unit oral tid w meals levothyroxine sodium mcg po daily lorazepam mg po q8h prn anxiety nausea omeprazole mg po daily ondansetron odt mg po q8h prn nausea vomiting first line pyridoxine mg po daily pyridoxine mg po daily turmeric capsule oral daily venlafaxine xr mg po dinner vitamin d unit po daily discharge disposition home discharge diagnosis fever pericarditis metastatic pancreatic cancer discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent md completed by

name unit no admission date discharge date date of birth sex f service medicine allergies tetracycline attending chief complaint abnormal lfts major surgical or invasive procedure ercp with stent history of present illness ms is a woman with history of depression hypothyroidism nephrolithiasis and several months of morning fogginess transferred from after her pcp referred her to the ed for elevated lfts and mri reportedly showed cbd stricture vs malignancy or stone ruqus in our ed confirmed cbd intrahepatic biliary ductal dilation and cbd up to 7cm no evidence of cholangitis admitted for further workup including mrcp ms presented to her pcp about month or two ago complaining of feeling foggy in the morning the sensation that she could not concentrate initially her tsh was rechecked and her levothyroxine dose was adjusted upwards to her current dose this did not seem to help so her pcp did routing liver function tests and discovered elevated ast alt and alkaline phosphatase wokrup including hbv hcv hav were all negative and per records she had an ruqus done on which showed dilated hepatic bile duct and possible fatty infiltrate she had noted etoh use the weekend prior she was referred to her local hospital and reportedly an mri was done which showed cbd stricture vs malignancy or stone and referred her to for potential ercp upon arrival to us she was feeling well no complaints currently she denies ab pain but does note that her urine has seemed more dark lately and she did have one bowel movement about a week ago that was tan colored instead of her usual brown ros also notes headaches occasionally also notes feeling slightly bloated in her abdomen comprehensive ros was otherwise negative past medical history hypothyroidism 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 many years ago and has since passed away from other causes she cannot recall the etiology if any to which this was attributed to physical exam vs p82 r18 on ra gen alert lying in bed no acute distress alert and talkative with a accent heent mmm anicteric sclera no conjunctival pallor neck supple without lad pulm clear no wheeze rales or rhonchi cor rrr normal s1 s2 no murmurs abd soft nt nd normal bs extrem warm no edema neuro cn ii xii grossly intact motor function grossly normal pertinent results 36pm lactate 19pm glucose urea n creat sodium potassium chloride total co2 anion gap 19pm estgfr using this 19pm alt sgpt ast sgot alk phos tot bili dir bili indir bil 19pm lipase 19pm albumin 19pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 19pm neuts monos eos basos im absneut abslymp absmono abseos absbaso 19pm plt count 19pm ptt impression normal major papilla cannulation of the biliary duct was successful and deep with a sphincterotome using a free hand technique a single stricture that was mm long was seen at the middle third of the common bile duct just below the cystic duct takeoff there was moder post obstructive dilation with the upstream bile duct measuring 15mm a sphincterotomy was performed in the o clock position using a sphincterotome over an existing guidewire spy cholangioscopy was performed stricture was noted under direct visualization it appeared as a tapered lumenal narrowing without neovascularization tumor vessels or papillary mucosal projections noted the main bile duct appeared normal to the bifurcation cystic duct also appeared normal forceps were taken of the stricture for histopathology cytology samples were obtained for histology using a brush in the middle third of the common bile duct a 7cm by biliary stent was placed successfully using a oasis stent introducer kit recommendations return to ward under ongoing care npo overnight with aggressive iv hydration with lr at cc hr if no abdominal pain in the morning advance diet to clear liquids and then advance as tolerated ct pancreas protocol ciprofloxacin 500mg po bid x days follow up path and cytology reports further management will depend on the results please call dr office at in days for the results repeat ercp in weeks for stent pull and re evaluation follow up with dr as previously scheduled follow for response and complications if any abdominal pain fever jaundice gastrointestinal bleeding please call ercp fellow on call brief hospital course a p woman with history of depression hypothyroidism nephrolithiasis and several months of morning fogginess transferred from after her pcp referred her to the ed for elevated lfts and ultrasound showing intrahepatic ductal dilatation ruqus in our ed confirmed cbd intrahepatic biliary ductal dilation and cbd up to 7cm no evidence of cholangitis admitted for further workup including mrcp cbd stricture bile obstruction asymptomatic infiltrative pattern with elevated ast alt into the 100s with moderately elevated alk phos would expect a higher bilirubin with biliary obstruction but seems like it may have been higher recently given previous acholic stools and dark urine which were reported the biliary ductal dilatation is concerning for obstruction either due to stone or malignancy there is no evidence of cholangitis either on exam or by labs mrcp at osh reviewed consistent for cbd stricture near cystic duct dilated pancreatic duct no clear mass stone she underwent ercp confirming cbd stricture bx sent stent placed she did well post procedure and her diet was advanced she was given cipro 500mg bid x5 days her plan will be for her to follow up with ercp and have repeat ercp to address stent she will also have cta pancreas ordered by ercp team they will follow up with her and regarding biopsy results leg swelling minimal difference on l side negative for dvt hypothyroidism depression continued home meds hypertension sbp up to 160s since arrival no prior dx of essential htn will continue to follow for now pcp follow up on admission the preadmission medication list is accurate and complete venlafaxine mg po daily levothyroxine sodium mcg po daily discharge medications levothyroxine sodium mcg po daily venlafaxine xr mg po daily ciprofloxacin hcl mg po q12h duration days rx ciprofloxacin hcl mg tablet s by mouth twice a day disp tablet refills discharge disposition home discharge diagnosis cbd stricture hypothyroidism depression discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted for ercp and were found to have a stricture in your common bile duct you will need to return for another procedure to have your stent removed you will also need to schedule a ct scan of your liver and pancreas please call the radiology dept to schedule this test asap you will be called with the results of your biopsy and for follow up with the gi team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies tetracycline attending chief complaint monitoring post ercp eus for pancreatic mass major surgical or invasive procedure egd eus history of present illness with hx of depression hypothyroidism nephrolithiasis admitted to for workup of elevated lfts and mri with cbd stricture vs malignancy or stone s p nondiagnostic ercp and bx on readmitted for monitoring after ercp and eus with fna in setting of cm pancreatic head mass please see hpi from discharge summary dated for detailed history of events leading up that hospitalization since leaving the hospital in she notes that she has actually felt better with improvement in morning fogginess arthralgias and more energetic she notes that she has stopped her simvastatin at the suggestion of her pcp and wonders if her improved symptoms are related to this medication change or perhaps to a chance in her thyroid medication she notes limited appetite as well as ongoing early satiety she has an epigastric heaviness that comes and goes with no clear precipitating factors on the floor abdominal discomfort is present wraps around to bilateral flanks at present denies fevers chills nausea vomiting diarrhea she has not had a bm since her colonoscopy on reportedly negative which was done at per ercp team eus done today with fna fnb of pancreas mass and ercp with removal of plastic stent brushings of distal cbd stricture and placement of mm x mm fully covered metal stent postprocedure pt was noted to have severe pain received dilaudid mg iv and stat kub which did not reveal free air per ercp request ct abd pelvis to rule out perforation if kub negative ros all else negative 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 admission vs ra gen alert lying in bed no acute distress interactive heent mmm anicteric sclera no conjunctival pallor clear oropharynx neck supple no cervical or supraclavicular lad pulm clear no wheeze rales or rhonchi cv rrr normal s1 s2 no murmurs abd soft nd tender to palpation at epigastrium without rebound or guarding bs no hepatomegaly extrem warm no edema gu no foley neuro cn ii xii grossly intact motor function grossly normal discharge vs ra gen sitting up in bed comfortable appearing eyes eomi ent op clear mmm heart rrr no mrg lungs cta bilaterally abd soft very mild tenderness to epigastric palpation much improved from prior no rebound guarding no cva tenderness hypoactive bowel sounds ext no edema skin no rashes vasc dp radial pulses neuro aox3 moving all extremities psych appropriate pertinent results admission 40am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 40am blood urean creat na k cl hco3 angap 40am blood alt ast alkphos amylase totbili dirbili indbili discharge 20am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 20am blood glucose urean creat na k cl hco3 angap 20am blood alt ast alkphos totbili eus impression a ill defined mass was noted in the head of the pancreas fna and fnb were performed a total of four needle passes were made into the mass the specimens were sent for cytology and pathology the mass appeared to abut the portal vein the right hepatic artery could not be well visualized a previously placed plastic biliary stent was noted the pancreas mass appeared to impinge upon the bile duct at the level of the head of the pancreas ercp impression the scout film showed evidence of a previously placed plastic biliary stent the previously placed plastic biliary stent was found in the major papilla the stent was removed with a snare and sent for cytology evidence of a previous sphincterotomy was noted in the major papilla cannulation of the biliary duct was successful and deep with a sphincterotome using a free hand technique contrast medium was injected resulting in complete opacification a single stricture that was mm long was seen at the middle third of the common bile duct just below the cystic duct takeoff with moderate post obstructive dilation brushings were obtained of the stricture with a cytology brush a mm x mm wallflex biliary fully covered metal stent ref lot was placed successfully into the common bile duct excellent drainage of bile and contrast was noted endoscopically and fluoroscopically otherwise normal ercp to third part of the duodenum ct abd pelvis no evidence of free air or leakage of contrast within the abdomen to indicate bowel perforation pneumobilia consistent with recent ercp and stent placement area fullness at the head of the pancreas may be region that was recently biopsied the pancreatic duct upstream of the area of fullness is dilated significant peripancreatic stranding may be due to pancreatitis fna pancreas mass fine needle aspiration pancreas mass suspicious for malignant cells hypocellular degenerated specimen with scattered small clusters of very atypical epithelioid cells cytology common bile duct stent positive for malignant cells consistent with adenocarcinoma cytology common bile duct brushing positive for malignant cells consistent with adenocarcinoma see note brief hospital course this is a year old female with past medical history of recent admission for biliary stricture admitted following eus and ercp post procedure course complicated by post ercp pancreatitis now improved with conservative management and ready for discharge home with scheduled follow up in multidisciplinary pancreas clinic biliary obstruction malignancy of head of pancreas patient with recent ercp and stenting for pancreas mass who was admitted after repeat ercp with metal stent placement and eus with fna fnb of mass suspected to be malignancy preliminary cytology returned consistent with malignancy specifically adenocarcinoma these results were discussed with patient and patient was scheduled for multi disciplinary pancreas clinic follow up patient was treated with post ercp antibiotic prophylaxis ciprofloxacin 500mg bid x days at time of discharge igg subclasses were pending post ercp acute hospital course was complicated by persistant pain and and nausea following ercp ct abd pelvis was performed to rule out perforaction but instead showed stranding at pancreas consistent with pancreatitis patient managed conservatively with iv fluids npo and prn anti pain nausea meds patient subsequently able to advance diet and tolerate regular food discharged home with above follow up constipation patient reported that she had not moved her bowels for several days leading up to admission no signs obstruction patient started on bowel regimen and after pancreatitis began to resolve was able to have a bowel movement hypothyroidism continued levothyroxine depression continued venlafaxine transitional issues contact husband code status full igg subclasses pending at discharge gi mucosal biopsy pending at discharge patient scheduled for follow up with multidisciplinary pancreas clinic medications on admission the preadmission medication list is accurate and complete levothyroxine sodium mcg po daily venlafaxine xr mg po daily discharge medications levothyroxine sodium mcg po daily venlafaxine xr mg po daily ciprofloxacin hcl mg po q12h duration days rx ciprofloxacin hcl mg tablet s by mouth every twelve hours disp tablet refills discharge disposition home discharge diagnosis post ercp acute pancreatitis constipation biliary obstruction head of pancreas mass anemia hypothyroidism depression discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions ms it was a pleasure caring for you at you were admitted after an ercp endoscopic retrograde cholangiopancreatography and eus endoscopic ultrasound with biopsy of your pancreas after your procedure you had pain and nausea that was likely due to inflammation near the site of your procedure this is called pancreatitis you were treated and improved you are now ready for discharge as we discussed your biopsy was concerning for a malignancy we have made an appointment for you in the multi disciplinary pancreas clinic to further evaluate your imaging and biopsy results it will be important for you to finish a day course of antibiotics to prevent infection after your ercp 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 abdominal pain major surgical or invasive procedure none history of present illness years old woman with past medical history of hypertension comes to the ed complaining of abdominal pain patient refers she was in her usual state of health until days ago when she started having intermittent severe crampy abdominal pain she refers that sometimes the pain was so severe that it was associated with nausea but no emesis she also refers some chills and subjective fevers but no recorded fevers and loose bowel movements yesterday her pain worsened so she called her pcp who ordered cbc and ua both of which were normal so she was sent home this morning her pain was again worse so she went back to her pcp and had done a ct scan of abdomen and pelvis that showed acute diverticulitis with small abscess so she was referred to the ed for surgical evaluation past medical history htn diverticulosis social history family history non contributory physical exam physical exam upon admission vital signs ra general aaox3 nad heent ncat eomi perrla no scleral icterus mucosa moist no lad cardiovascular r r r s1 s2 no m r g pulmonary cta no crackles or rhonchi gastrointestinal soft non distended mildly tender diffusely in lower abdomen no guarding rebound or peritoneal signs bsx4 ext ms skin no c c e feet warm good perfusion neurological reflexes strength and sensation grossly intact cnii xii wnl physical examination upon discharge general nad cv ns1 s2 no murmurs lungs clear abdomen hypoactive bs soft non tender ext no calf tenderness bil no pedal edema bil neuro alert and oriented x speech clear pertinent results 15am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 49am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 44pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 15am blood plt 15am blood glucose urean creat na k cl hco3 angap 30pm blood glucose urean creat na k cl hco3 angap 15am blood calcium phos mg 38pm blood lactate ct scan abdomen and pelvis sigmoid diverticulitis with cm intramural abscess no evidence of macro perforation mm hypodensity within the pancreatic body likely represents a benign intra ductal papillary mucinous neoplasm nonurgent mrcp is recommended for further evaluation recommendation s non urgent mrcp notification the findings were discussed with m d by m d on the telephone on at pm minutes after discovery of the findings brief hospital course year old female admitted to the hospital with abdominal pain upon admission the patient was made npo given intravenous fluids and underwent imaging she was reported to have sigmoid diverticulitis with cm intramural abscess the patient was started on a course of intravenous ciprofloxacin and flagyl and placed on bowel rest her white blood cell count was monitored after the patient s abdominal pain decreased she was started on clears and advanced to a regular diet the patient was discharged home on hd her vital signs were stable and she was afebrile she was tolerating a regular diet and voiding without difficultly she was ambulatory and return of bowel function discharge instructions were reviewed and questions answered the patient was given a prescription for completion of a course of ciprofloxacin and flagyl the patient was instructed to follow up with her primary care provider of note incidental finding on cat scan imaging showed a mm hypo density within the pancreatic body likely represents a benign intra ductal papillary mucinous neoplasm non urgent mrcp is recommended for further evaluation the patient was informed of this finding and given a copy of her report medications on admission estradiol estrace estrace mg gram vaginal cream gram use as directed prn prescribed by other provider losartan losartan mg tablet tablet s by mouth q day niacin niacin er mg tablet extended release hr tablet s by mouth once a day raloxifene raloxifene mg tablet tablet s by mouth daily rhizinate x3 dosage uncertain prescribed by other provider medications otc aspirin aspirin mg tablet delayed release tablet s by mouth daily prescribed by other provider cholecalciferol vitamin d3 vitamin d3 vitamin d3 unit capsule capsule s by mouth daily prescribed by other provider multivit min lycop lut herb phytomulti phytomulti mg mg mg tablet tablet s by mouth daily prescribed by other provider vit a and d3 in cod liver oil cod liver oil cod liver oil unit unit ml oral liquid tbsp by mouth daily prescribed by other provider discharge medications acetaminophen mg po q6h prn pain mild ciprofloxacin hcl mg po q12h duration days rx ciprofloxacin hcl cipro mg tablet s by mouth every twelve hours disp tablet refills metronidazole mg po q8h duration days last dose rx metronidazole flagyl mg tablet s by mouth every eight hours disp tablet refills aspirin mg po daily losartan potassium mg po daily discharge disposition home discharge diagnosis diverticulitis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted to the hospital with abdominal pain you underwent imaging which showed sigmoid diverticulitis with a intra mural abscess you were placed on bowel rest and given a course of antibiotics your abdominal pain has decreased and you have resumed a diet you are being discharged home with the following recommendations 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 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 followup instructions

name unit no admission date discharge date date of birth sex f service orthopaedics allergies no known allergies adverse drug reactions attending chief complaint left hip osteoarthritis major surgical or invasive procedure left hip replacement anterior approach history of present illness year old female with left hip osteoarthritis who has failed conservative measures and is here for definitive surgery past medical history htn diverticulosis 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 aquacel dressing with scant serosanguinous drainage thigh full but soft no calf tenderness strength silt nvi distally toes warm pertinent results 45am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 45am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 43pm blood hct 45am blood glucose urean creat na k cl hco3 angap 45am blood calcium phos mg 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 pod urinary retention patient was straight catheterized on pod for urinary retention she was then able to void without incident she also felt pain and a pop sensation while transitioning from sitting to standing with ot a new x ray was obtained which results showed avulsion fracture of the greater trochanter imaging reviewed by dr felt this area was likely known bony fragment seen intra op no changes in weight bearing status pod patient worked again with physical and did well without further issues otherwise pain was controlled with a combination of iv and oral pain medications the patient received aspirin mg twice daily for dvt prophylaxis starting on the morning of pod the surgical dressing will remain on until pod after surgery 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 dressing was intact the patient s weight bearing status is weight bearing as tolerated on the operative extremity with anterior precautions no hip bridging no repetitive resistant hip flexion walker or two crutches wean as able ms is discharged to home with services in stable condition medications on admission acetaminophen mg po q6h prn pain mild fever aspirin mg po daily docusate sodium mg po bid estrace estradiol mg gram vaginal asdir losartan potassium mg po daily multivitamins tab po daily gaviscon al hyd mg tr alg ac sod bicarb br aluminum hydrox magnesium carb mg oral asdir raloxifene mg oral daily niacin sr mg po daily discharge medications oxycodone immediate release mg po q4h prn pain pantoprazole mg po q24h continue while on week course of aspirin mg twice daily senna mg po bid acetaminophen mg po q8h aspirin ec mg po bid resume aspirin mg every day after week course of aspirin mg twice daily docusate sodium mg po bid gaviscon al hyd mg tr alg ac sod bicarb br aluminum hydrox magnesium carb mg oral asdir losartan potassium mg po daily multivitamins tab po daily niacin sr mg po daily held estrace estradiol mg gram vaginal asdir this medication was held do not restart estrace until you ve been cleared by your surgeon held raloxifene mg oral daily this medication was held do not restart raloxifene until you ve been cleared by your surgeon discharge disposition home with service facility discharge diagnosis left hip 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 please do not take any non steroidal anti inflammatory medications nsaids such as celebrex ibuprofen advil aleve motrin naproxen etc until cleared by your physician anticoagulation please continue your aspirin mg twice daily with food for four weeks to help prevent deep vein thrombosis blood clots continue pantoprazole daily while on aspirin to prevent gi upset x weeks if you were taking aspirin prior to your surgery take it at mg twice daily until the end of the weeks then you can go back to your normal dosing wound care please remove aquacel dressing on pod after surgery it is okay to shower after surgery after days but no tub baths swimming or submerging your incision until after your four week checkup please place a dry sterile dressing on the wound after aqaucel is removed 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 once at home home dressing changes as instructed and wound checks activity weight bearing as tolerated with walker or crutches wean assistive device as able anterior precautions no hip bridging no repetitive resistant hip flexion no strenuous exercise or heavy lifting until follow up appointment mobilize frequently physical therapy wbat lle no hip bridging and no repetitive resistant hip flexion wean assistive device as able i e crutches or walker mobilize frequently treatments frequency remove aquacel pod after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed 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 trauma stabbing left flank facial trauma major surgical or invasive procedure orif of right mandibular fracture mmf left mandible ex lap and control of left intercostal artery bleed history of present illness year old male who was stabbed in the left flank as well as struck the left side of face patient went to an outside hospital where he was found to have facial fracture as well as states left sided jaw pain patient denies any nausea or vomiting past medical history none social history family history non contributory physical exam physical examination upon admission constitutional comfortable heent laceration underneath chin 9cm blood from left tympanic membrane chest clear to auscultation cardiovascular regular rate and rhythm normal first and second heart sounds abdominal left flank stab wound gu flank no costovertebral angle tenderness extr back no cyanosis clubbing or edema skin no rash neuro speech fluent psych normal mood exam on discharge vs 98ra gen nad a ox3 neuro wnl heent peerl eomi neck wnl cardiac rrr no mrg abd soft nt nd w o r g wound c d i w o erythema or induration pertinent results 20am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 35am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 32am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 20am blood plt 00am blood ptt 20am blood glucose urean creat na k cl hco3 angap 20am blood calcium phos mg 12am blood type art po2 pco2 ph caltco2 base xs 22am blood glucose lactate na k cl 22am blood hgb calchct o2 sat 22am blood freeca cat scan of the orbit no temporal bone fracture partially visualized left mandibular fracture better seen on the dedicated facial bone ct cta head normal head and neck cta no acute intracranial abnormality displaced fracture involving the left mandibular condyle and a non displaced fracture involving the anterior body of the right mandible between the first and second premolar extending posteriorly and superiorly soft tissue swelling and laceration involving the chin ct of the sinus comminuted impacted fracture of the left mandibular condyle with involvement of the temporal mandibular joint with associated small foci of air brief hospital course mr is a year old male who was admitted to on with a stab wound to the left flank and facial fractures on he was taken to the operating room with the acute care surgery team for an exploratory laparotomy was consulted for the right body mandible fracture and left subcondylar mandible fracture on he was taken to the operating room with omfs for orif right body fracture and closed reduction maxillomandibular fixation icu course patient was taken to the operating room for an exploratory laparotomy please see operative note for further details he was taken to the icu intubated post op not on any pressors he remained hemodynamically stable with stable hcts he was extubated on pod0 without issues omfs was consulted for his open mandibular fracture his icu course by systems is as follows neuro his pain was well controlled with fent and then intermittent dilaudid cv hd stable resp he was extubated on pod0 without issues gi he was initially npo ivf until his hcts remained stable heme hcts remained stable id unasyn was started for an open mandibular fracture he completed days of ciprodex ear drops the patient worked with who determined that discharge to was appropriate the hospital course was otherwise unremarkable and only significant for disposition and placement due to the fact the patient is homeless 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 able to ambulate ad lib the patient will follow up with dr at of dental medicine unit for the acute care surgery clinic on and for outpatient audiogram on 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 medications on admission none discharge medications oxycodone liquid mg po q4h prn pain rx oxycodone mg ml ml by mouth q4hrs disp milliliter refills acetaminophen liquid mg po q6h prn pain chlorhexidine gluconate oral rinse ml oral bid docusate sodium liquid mg po bid milk of magnesia ml po q6h prn constipation pseudoephedrine mg po q6h prn congestion senna mg po bid prn constipation sodium chloride nasal spry nu qid prn congestion trazodone mg po qhs prn insomnia discharge disposition extended care facility discharge diagnosis trauma left rp abdominal wall bleeding left mandibular condyle fracture left mandibular fossa fracture left tmj dislocation discharge condition mental status clear and coherent speaking level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted to the hospital after you involved in an altercation which resulted in a stabbing injury to the left flank and injuries to the left side of the face you sustained a fracture to your jaw and an abdominal wall bleed you were taken to the operating room for an exploratory laparotomy and repair of your jaw you incisional pain has been controlled with oral analgesia your vital signs have been stable and you are preparing for discharge with the following instructions 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 high blood pressure major surgical or invasive procedure none history of present illness speaking man w pmh of htn who presents the emergency room for evaluation of high blood pressure patient was in usual state of health and was asymptomatic but decided to go to his pcp s office for routine care because he hadn t seen a doctor for years and was found to have bp left arm right arm he was asymptomatic he was previously on antihypertensives but stopped these medications in because he says he felt fine without them which is the last time he saw a doctor he reports a mild headache that started earlier was not sudden in onset and has gotten better since this morning he has not had consistent headaches prior to this one denies vision changes blurry vision chest pain or shortness of breath nausea vomiting difficulties urinating lightheadedness both recently and in the past his pcp then sent him to the ed in the ed initial vital signs were ra labs were notable for cr wbc alt ast ap tb bnp trop negative x2 imaging cxr showed enlarged cardiomediastinal silhouette mild pulmonary vascular congestion subtle right base opacity most likely relates to vascular congestion although underlying infection is difficult to exclude ct head showed no acute intracranial process possible subtle ectasia of the distal left vertebral artery and proximal basilar artery the patient was given iv labetalol mg iv labetalol mg po ng labetalol mg po aspirin mg vitals prior to transfer were ra upon arrival to the floor patient reports ongoing headache which is frontal and not associated with change in vision or other neurologic complaints continues to deny other symptoms as mentioned above past medical history hypertension social history family history negative for known cancers cad dm mom with htn alive father died in his of unknown causes physical exam admission vitals afebrile 100ra general pleasant well appearing in no apparent distress heent normocephalic atraumatic no conjunctival pallor or scleral icterus perrla eomi op clear neck supple no lad no thyromegaly jvp not elevated cardiac regular rate rhythm normal s1 s2 no murmurs rubs or gallops pulmonary clear to auscultation bilaterally without wheezes or rhonchi abdomen normal bowel sounds soft non tender non distended no organomegaly extremities warm well perfused no cyanosis clubbing or edema skin without rash neurologic a ox3 cn ii xii grossly normal normal sensation with strength throughout no pronator drift cerebellar function intact gait assessment deferred psychiatric listen responds to questions appropriately pleasant discharge general pleasant well appearing in no apparent distress heent normocephalic atraumatic no conjunctival pallor or scleral icterus perrla eomi op clear neck supple no lad no thyromegaly jvp not elevated cardiac regular rate rhythm normal s1 s2 no murmurs rubs or gallops pulmonary clear to auscultation bilaterally without wheezes or rhonchi abdomen normal bowel sounds soft non tender non distended no organomegaly extremities warm well perfused no cyanosis clubbing or edema skin without rash neurologic a ox3 cn ii xii grossly normal strength and sensation grossly intact psychiatric listen responds to questions appropriately pleasant pertinent results admission 55pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 55pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 55pm blood ptt 55pm blood glucose urean creat na k cl hco3 angap 55pm blood alt ast alkphos totbili 55pm blood probnp 55pm blood ctropnt 21am blood ctropnt 55pm blood albumin calcium phos mg pertinent 05am blood alt ast ld ldh alkphos totbili 55pm blood lipase 05am blood albumin calcium phos mg cholest 05am blood hba1c eag 05am blood triglyc hdl chol hd ldlcalc 05am blood tsh discharge 40am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 40am blood glucose urean creat na k cl hco3 angap 40am blood calcium phos mg imaging cxr pa l enlarged cardiomediastinal silhouette mild pulmonary vascular congestion subtle right base opacity most likely relates to vascular congestion although underlying infection is difficult to exclude nchct no acute intracranial process possible subtle ectasia of the distal left vertebral artery and proximal basilar artery ekg nsr bpm normal axis incomplete rbbb lvh w secondary repolarization abnormalities lae renal artery doppler no evidence of renal artery stenosis in the left kidney and likely no stenosis in the right kidney however the doppler examination is somewhat limited due to the patient s limited ability to hold his breath tte the left atrial volume index is moderately increased the estimated right atrial pressure is mmhg there is severe symmetric left ventricular hypertrophy the left ventricular cavity size is normal overall left ventricular systolic function is mildly depressed quantitative biplane lvef secondary to mild global hypokinesis with slightly worse function of the basal mid inferior and inferoseptal walls tissue doppler imaging suggests an increased left ventricular filling pressure pcwp 18mmhg right ventricular chamber size and free wall motion are normal the right ventricular free wall is hypertrophied the aortic root is mildly dilated at the sinus level the ascending aorta is mildly dilated the aortic arch 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 structurally normal there is no mitral valve prolapse mild mitral regurgitation is seen there is mild pulmonary artery systolic hypertension the end diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension there is a very small pericardial effusion there are no echocardiographic signs of tamponade impression severe concentric left ventricular hypertrophy with mildly depressed global and regional systolic dysfunction and increased filling pressure mild mitral regurgitation mild pulmonary artery systolic hypertension mild dilatation of the ascending aorta and arch very small pericardial effusion findings are suggestive of hypertensive myopathy with possible underlying cad although an infiltrative process cannot be excluded brief hospital course portugese speaking man w pmh of htn who presents the emergency room for evaluation of high blood pressure hypertensive urgency patient presenting with bp of at his pcp asymptomatic other than a headache without signs symptoms of end organ damage bnp mildly elevated without prior comparison ekg w lvh trop neg x cr at baseline renal artery doppler with no evidence of renal artery stenosis he was previously on a drug regimen of hctz lisinopril nifedipine and metoprolol labetalol was initiated in the ed with resultant bradycardia to started on chlorthalidone 25mg daily amlodipine 10mg daily lisinopril 20mg daily and carvedilol 5mg bid with improvement in blood pressures cardiovascular disease risk patient at increased risk for cardiovascular disease given longstanding poorly controlled hypertension significant lvh noted on ekg ef with significant lvh and wall motion abnormalities seen on tte ascvd risk based on tc of hdl hba1c started on asa daily atorvastatin 40mg daily transaminitis mild elevation ast alt initially thought to be due to nash given obesity bmi last viral serologies from showed hep a immunity otherwise unremarkable hepatitis serologies sent which were negative transaminitis resolved on repeat labs suggesting it may have been to mild hepatic ischemia in the setting of hypertension transitional issues continue to monitor bp and adjust blood pressure medications patient started on lisinopril should have lytes checked at follow up appointment he needs outpatient work up for cad given focal wall motion abnormalities on tte continue counseling on importance of medication compliance continue asa statin continue to monitor cholesterol and consider titration to high intensity statin if inadequate response to moderate intensity contact wife or code status full code confirmed medications on admission none discharge medications amlodipine mg po daily please take in the evening rx amlodipine mg tablet s by mouth daily in the evening disp tablet refills aspirin mg po daily rx aspirin mg tablet s by mouth daily disp tablet refills atorvastatin mg po qpm rx atorvastatin mg tablet s by mouth daily disp tablet refills carvedilol mg po bid rx carvedilol mg tablet s by mouth twice a day disp tablet refills chlorthalidone mg po daily please take in the morning rx chlorthalidone mg tablet s by mouth daily in the morning disp tablet refills lisinopril mg po daily please take in the evening rx lisinopril mg tablet s by mouth daily in the evening disp tablet refills discharge disposition home discharge diagnosis primary hypertensive urgency secondary congestive heart failure hyperlipidemia pre diabetes cardiovascular disease risk discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr thank you for choosing to receive your care at you were admitted for a very high blood pressure in the setting of stopping taking your blood pressure medications several years ago we restarted your blood pressure medications with good improvement in your pressures we also did an ultrasound study of your heart which showed that the high blood pressure has decreased its efficiency you had blood tests for cholesterol and diabetes which showed high cholesterol and risk for diabetes you should try to minimize sugary and fatty foods and limit carbohydrates in your diet moving forward you were prescribed new medications here in the hospital which you should take moving forward you should also follow up with your primary care provider at the appointment listed below moving forward you should exercise caution when standing up quickly because your body is used to the higher pressures it will eventually adjust so that you don t become dizzy when you stand we wish you the best with your ongoing recovery sincerely your care team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies vancomycin attending chief complaint left arm infection major surgical or invasive procedure drainage of abscess left arm on and history of present illness mr is a yo m with history of ivdu presenting with left arm swelling and pain patient first noticed pain and swelling his left arm days ago at night after injecting heroin on that day he notes that he was with friends who were using and so he used with them terms of his heroin use he is not sure what type he uses and describes it as brown beige rock that he dissolves tap water he gets his needles from needle exchange or from the pharmacy and usually uses them twice the needle he used during his last injection was a second time use he denies cleaning his arm before injecting and reports using the cigarette filter as a cotton he notes chills episodes of night sweats some occasional feeling of being cold but no fevers he denies any prior history of infection from iv drug use he denies use of any other drugs he reports daily heroin use for almost years however he reports injecting heroin or times a month for the last few months after joining where he is getting daily methadone he notes he feels that he is well plugged with the clinic he is a part of and feels that he has reduced his use substantially he denies sharing needles recently he consents to hiv testing the ed initial vital signs were ra exam notable for extensive track marks on both arms and swelling erythema and tenderness left arm labs were notable for h h and absence of leukocytosis studies performed include na k cl bicarb bun cr and lactate bedside ultrasound that showed no fluid collection patient was given clindamycin mg iv once vitals on transfer ra patient was admitted due to substantial infection which should improve prior to discharge due to poor follow up on the medicine floor patient was hemodynamically stable and no acute distress he was continued on iv clindamycin overnight past medical history iv drug use hepatitis c bipolar alcohol abuse social history family history mother with diabetes and heart problems physical exam physical exam on admission vitals t hr bp rr sao2 ra weight kg general well appearing no acute distress heent eomi cv rrr no murmurs lungs clear to auscultation bilaterally no wheezes rales or rhonci abdomen normal bowel sounds soft non tender to palpation all quadrants ext peripheral pulses skin multiple tattoos on upper extremities and chest left arm with notable x cm abscess on forearm warm to the touch with tenderness and overlying erythema of the skin strength sensation and pulse intact the arm no other notable areas of injection appreciated physical exam on discharge vitals tmax ra general well appearing no acute distress cv rrr no murmurs lungs clear to auscultation bilaterally no wheezes rales or rhonci abdomen normal bowel sounds soft non tender to palpation all quadrants upper extremity left arm with dressing on motor and sensation grossly intact bilaterally pertinent results on admission 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 glucose urean creat na k cl hco3 angap 49pm blood lactate on discharge 36am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 36am blood glucose urean creat na k cl hco3 angap 36am blood calcium phos mg pertinent tests 00am blood alt ast alkphos totbili 00am blood calcium phos mg iron 00am blood caltibc vitb12 ferritn trf 00am blood crp 00am blood hiv ab negative imaging ultrasound left arm subcutaneous left forearm fluid collection consistent with abscess measuring x x cm micro pm abscess source arm l fluid should not be sent swab transport media submit fluids a capped syringe no needle red top tube or sterile cup gram stain final per 1000x field polymorphonuclear leukocytes per 1000x field gram positive rod s per 1000x field gram positive cocci pairs chains and clusters per 1000x field gram negative rod s smear reviewed results confirmed fluid culture preliminary streptococcus anginosus group moderate growth sensitivities mic expressed mcg ml streptococcus anginosus group penicillin g s vancomycin s anaerobic culture preliminary no anaerobes isolated brief hospital course yo m with history of iv heroine use and hepatitis c who presented with left arm abscess cellulitis infection cellulitis abscess patient presented with left arm swelling erythema and tenderness location of ivd injected days ago although bedside us did not show fluid collection the ed the notable fluid collection under the skin tenderness to palpation and erythema were concerning for an underlying abscess repeat ultrasound showed fluid collection consistent with abscess measuring x x cm s p i d x2 on and by plastic surgery patient was started on clindamycin day and then cipro day was added to cover from gram and anaerobes pain control was achieved with tylenol and methadone see below and occasionally oxycodone mainly when pain was severe after i d speciation of gram positive cocci showed streptococcus anginosus which was sensitive to vancomycin and penicillins otherwise anaerobic cultures did not result by the time of discharge the significance of the gram positive rods was unclear as they did not speciate and were felt by the microbiology to have potentially been gram positive diplococci pt was discharged with augmentin and metronidazole with a planned day course he was also scheduled for follow up with plastic surgery iv drug use patient with iv heroine use is currently receiving methadone at we continued methadone mg daily of note pt frequently went for what he described as smoke breaks during this hospitalization lasting up to hours uds was initially positive for opiates the setting of recent oxycodone use his uds became negative for opiates the day before discharge hepatitis c patient has a known history of hepatitis c infection lft s were notable for transaminitis similar to prior with and platelets within normal limits normocytic anemia h h was on admission which was stable compared to prior iron studies were within normal limits except for high iron of vitamin b12 was also within normal limits bipolar patient is not on any medications transitional issues pt should complete a day course of augmentin and ciprofloxacin day end and ensure resolution of symptoms pt scheduled to follow up with plastic surgery continue daily packing change patient has anemia h h of with elevated rdw and normal mcv monitor h h and consider further anemia workup patient has a known history of hepatitis c infection please monitor medications on admission the preadmission medication list is accurate and complete methadone mg po daily discharge medications methadone mg po daily naloxone mg iv once mr1 opiate overdose duration dose spray 1ml each nostril repeat 3min if no response rx naloxone mg ml ml intranasal once disp syringe refills amoxicillin clavulanic acid mg po q8h rx amoxicillin pot clavulanate mg mg tablet s by mouth every eight hours disp tablet refills metronidazole flagyl mg po q8h rx metronidazole flagyl mg tablet s by mouth every eight hours disp tablet refills discharge disposition home discharge diagnosis primary diagnosis left arm abscess and cellulitis secondary diagnoses hepatitis c virus infection anemia bipolar discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr you came to the hospital because you were experiencing left arm swelling and pain after injecting drugs the arm ultrasound of the arm showed a deep abscess so the plastic surgery team drained it twice we treated you with antibiotics which you should continue as prescribed you are being discharged with new antibiotics amoxicillin clavulanate and metronidazole please take these times each day for the next days if you develop any rash or shortness of breath after taking your antibiotics please seek medical attention immediately please also do not drink alcohol while taking antibiotics as this can make you feel ill because it is so difficult to stop using it s important to know how to keep yourself as safe as possible until you are ready to quit follow these tips when injecting drugs wash your hands with soap and water first do not share needles and syringes always try to use a new needle syringe for each injection if you are re using a needle it must be cleaned before you use it if you use it over and over clean it every time the safest water is sterile water that you buy at the drug store if you have sterile water use water that you ve boiled for at least minutes boil just before using allowing a short time to cool use clean cotton from a dental pellet q tip or cotton ball if you have these filter paper or tampons may work do not use cigarette filters clean skin with alcohol before injection do not lick skin or needle this increases the risk of infection we are also discharging you with a medication called naloxone if you overdose on heroin this can save your life if you are administered this medication you will need go immediately to an emergency room this medication will only make you better for a short period of time and your life can be danger after the medication wears off make sure to follow up with you primary care doctor we have also scheduled you for an appointment with a plastic surgeon dr 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 vancomycin attending chief complaint leg pain major surgical or invasive procedure none history of present illness y o m w pmhx tibial fracture s p orif at ivdu and bipolar disorder who presented to for fever and left knee pain pt reports acute onset knee and lower leg pain this afternoon up to he notes associated erythema and swelling he has never had these symptoms before no numbness in left foot he denies any fever malaise sob cp or n v prior to presenting to of note pt underwent a right shoulder and left tibial orif with screw placement on at in the setting of an mva he also notes that he does use iv drugs and has not done so in years in the ed initial vitals ra there was a report that patient had recently used iv drugs and was confused in the ed pt denied this on the floor labs notable for cr crp cbc ua negative utox positive for opiates methadone stox pending at the time of transfer 3x bcx drawn imaging notable for tib fib ap lateral showed status post orif of the proximal tibia with plate and screw fixation with hardware in anatomic alignment very focal subtle linear lucency in the cortex of the medial metadiaphysis of the proximal left tibia just underlying hardware plate is of indeterminate age could relate to prior fracture or a more recent stress fracture no prior for comparison bedside u s without focal abscess in the knee cxr showed no focal consolidation pt had a joint aspiration showing wbc rbc patient given iv clindamycin mg ordered vitals prior to transfer ra on arrival to the floor pt reports continued pain and swelling in lle past medical history iv drug use hepatitis c bipolar alcohol abuse social history family history mother with diabetes and heart problems physical exam admission exam vitals ra general alert oriented no acute distress heent sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs clear to auscultation bilaterally no wheezes rales rhonchi cv regular rate and rhythm normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext wwp large area of warmth erythema and ttp along anterior aspect of lle dp pulses equal bilaterally msk rom of left knee could not be fully assessed due to pain with movement of left leg skin without rashes or lesions track marks on bilateral forearms surgical scar on anterior aspect of right shoulder neuro a ox3 grossly intact discharge exam vital signs tmax bp hr rr ra general alert oriented sitting up in bed comfortable eating breakfast lungs clear to auscultation bilaterally good air movement gallops abdomen soft non tender non distended bowel sounds present ext wwp mild erythema and ttp over large area of skin overlying the tibia exquistitely tender near proximal tibia no ttp at knee joint area msk rom of left knee could not be fully assessed due to pain with movement of left leg skin track marks on bilateral forearms surgical scar on anterior aspect of right shoulder neuro a ox3 grossly intact pertinent results admission labs 35pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 35pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 35pm blood ptt 35pm blood plt 35pm blood glucose urean creat na k cl hco3 angap 35pm blood crp 35pm blood asa neg acetmnp neg bnzodzp neg barbitr neg tricycl neg 46pm blood lactate imaging x ray tib fib findings patient is status post orif of the proximal tibia with plate and screw fixation hardware appears in anatomic alignment no hardware fracture is identified on the ap view there is very focal subtle linear lucency in the cortex of the medial metadiaphysis of the proximal tibia just underlying hardware plate is of indeterminate age no prior available for comparison well corticated mm ossific structure just lateral to the lateral tibial plateau is chronic there is likely a suprapatellar joint effusion patellar spurring is noted impression status post orif of the proximal tibia with plate and screw fixation with hardware in anatomic alignment very focal subtle linear lucency in the cortex of the medial metadiaphysis of the proximal left tibia just underlying hardware plate is of indeterminate age could relate to prior fracture or a more recent stress fracture cxr findings no focal consolidation is seen there is no pleural effusion or pneumothorax the cardiac and mediastinal silhouettes are grossly stable no overt pulmonary edema is seen chronic deformity of the proximal right humerus with hardware is seen but not well assessed on this study impression no focal consolidation ultrasound lower extremity impression no evidence of deep venous thrombosis in the left lower extremity veins discharge labs 30am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30am blood plt 30am blood glucose urean creat na k cl hco3 angap 30am blood calcium phos mg iron 30am blood caltibc vitb12 folate ferritn trf y o m w pmhx tibial fracture s p orif at ivdu and bipolar disorder who presented to for fever and left knee pain c w moderate cellulitis cellulitis the patient presented with left knee pain after undergoing a left tibial orf with screw placement on at in the setting of an mva in the afternoon of he developed acute onset left leg pain and swelling with difficulty ambulating he presented to where ortho evaluated in the or joint was aspirated and fluid not concerning for septic joint his crp and esr were low pointing away from osteomyelitis he was initially treated with iv clindamycin but was narrowed to cephalexin to complete a day course with noticeable improvement in his symptoms while in the hospital he was instructed to follow up with his pcp as an outpatient anemia the patient s cbc was notable for a hemoglobin around 12g iron studies were sent and were consistent with aocd history of ivdu on methadone he was given methadone mg daily with confirmation of this dose by his clinic he was given a letter indicating his last dose prior to discharge transitional issues the ed reported that the patient had taken heroin in the past month however on the floor the patient denied this stating it had been years prior his urine and blood toxicology were positive for opiates methadone and etoh at but nothing else full code contact friend on admission the preadmission medication list may be inaccurate and requires futher investigation methadone mg po daily discharge medications cephalexin mg po qid rx cephalexin mg tablet s by mouth four times a day disp tablet refills methadone mg po daily discharge disposition home discharge diagnosis primary cellulitis secondary history of iv drug use on methadone bipolar 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 you here at you came to the hospital with leg pain and swelling this was due to an infection of the skin also known as cellulitis we treated this infection with antibiotics the orthopedic surgeons evaluated you and saw that there was no infection in the knee joint itself you were discharged on oral antibiotics to finishing treating the skin infection 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 surgery allergies vancomycin thorazine contact metal agent attending chief complaint inguinal hernia major surgical or invasive procedure right sided inguinal hernia repair history of present illness per resident active ivda etoh abuse with hep c on methadone program who presented to the clinic with rt inguinal hernia the patient niticed the hernia m ago and had a few er visit for symoptomatic hernia it was never incarcerated and was not operated on denies trauma or heavy lifting he also denies fevers chills nausea of decreased po intake pt requesting the hernia to be repaired past medical history hcv bipolar disorder active ivdu heroin sometimes sniffs etoh active drinker came to the clinic s p car accident with lt tibial fx and shoulder injuries on for which he had surgery and plating in both sites per patient probably at past surgical history incision drainage and packing of left forearm abscess lt tibial and rt shoulder fixation social history family history nc physical exam vs t99 p45 pt states baseline bp rr ra general no acute distress alert and oriented x cardiac regular rhythm bradycardia nl s1 s2 resp clear to auscultation bilaterally abdomen soft non tender non distended no rebound tenderness guarding wounds abdominal lap sites with primary dgs slight serosanguinous staining x no periwound erythema or ecchymosis ext no lower extremity edema or tenderness pertinent results labs 00am blood hct 39pm blood hct brief hospital course the patient presented to pre op on pt was evaluated by anaesthesia and was taken to the operating room where he underwent a laparoscopic right inguinal hernia repair 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 the patient s home methadone dose and prn oxycodone he was transitioned to oral oxycodone acetaminophen upon discharge cv the patient remained stable from a cardiovascular standpoint vital signs were routinely monitored he was noted to have bradycardia during the hospitalization which was asymptomatic and the baseline heart rate per patient 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 tolerated a regular diet post operatively intake and output were closely monitored id the patient s fever curves were closely watched for signs of infection of which there were none heme the patient s blood counts were closely watched for signs of bleeding of which there were none prophylaxis the patient received subcutaneous heparin and dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible at the time of discharge the patient was doing well afebrile and hemodynamically stable the patient was tolerating a diet ambulating voiding without assistance and pain was well controlled the patient received discharge teaching and follow up instructions with understanding verbalized and agreement with the discharge plan medications on admission the preadmission medication list may be inaccurate and requires futher investigation methadone concentrated oral solution mg ml mg po daily discharge medications docusate sodium mg po bid prn constipation rx docusate sodium mg capsule s by mouth twice a day disp capsule refills oxycodone acetaminophen 5mg 325mg tab po q4h prn pain mild rx oxycodone acetaminophen mg mg tablet s by mouth q hours disp tablet refills methadone concentrated oral solution mg ml mg po as directed by prescribing provider home discharge diagnosis right sided inguinal hernia discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr you have undergone repair of your right sided inguinal hernia recovered in the hospital and are now preparing for discharge with the following instructions please call your doctor or nurse practitioner or return to the emergency department for any of the following you experience new chest pain pressure squeezing or tightness new or worsening cough shortness of breath or wheeze if you are vomiting and cannot keep down fluids or your medications you are getting dehydrated due to continued vomiting diarrhea or other reasons signs of dehydration include dry mouth rapid heartbeat or feeling dizzy or faint when standing you see blood or dark black material when you vomit or have a bowel movement you experience burning when you urinate have blood in your urine or experience a discharge your pain in not improving within hours or is not gone within 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 operating heavy machinery or consuming alcohol while taking pain medications incision care please call your doctor or nurse practitioner if you have increased pain swelling redness or drainage from the incision site avoid swimming and baths until your follow up appointment you may shower and wash surgical incisions with a mild soap and warm water gently pat the area dry if you have staples they will be removed at your follow up appointment if you have steri strips they will fall off on their own please remove any remaining strips days after surgery followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies vancomycin thorazine contact metal agent attending chief complaint hematemesis major surgical or invasive procedure none history of present illness undomiciled man with a history of hepatitis c opioid use disorder alcohol abuse who presented to the ed with day history of hematemesis the patient reports one episode days prior of a couple tablespoons of blood which then occurred again morning of admission he denies any blood in his stool or melena he denies any chest or abdominal pain he denies any shortness of breath he also reports some bilateral leg swelling without pain warmth fevers which has been present for several weeks for which another hospital prescribed him bactrim in the ed initial vitals were ra exam was notable for brown stool guaiac negative lower extremities with pitting edema and excoriations minimal erythema no warmth ekg sr na ni new twi v4 v6 labs without significant anemia and overall stable while there were no red flags in the ed with stable vs labs and no hematemesis in the ed given pulmonary vascular congestion on cxr ekg changes compared with prior and no documented history of chf he was admitted for further workup on the floor he was initially ornery and requesting to leave ama because he needed to use he arrived in dirty urine and stool covered clothing and he was cleaned up he reports feeling unwell like my body is deteriorating 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 diarrhea constipation or abdominal pain no dysuria denies arthralgias or myalgias otherwise ros is negative past medical history hcv bipolar disorder opioid use disorder with active iv heroin use last used a few hours prior to admission sometimes sniffs etoh active surgical history incision drainage and packing of left forearm abscess lt tibial and rt shoulder fixation bwh social history family history unknown physical exam admission physical exam vitals po ra pain scale general patient appears dishelved unkempt and foul smelling alert oriented and in no acute distress heent sclera anicteric poor dentition neck supple jvp low no lad appreciated lungs clear to auscultation bilaterally moving air well and symmetrically no wheezes rales or rhonchi appreciated cv regular rate and rhythm s1 and s2 clear and of good quality no murmurs rubs or gallops appreciated abdomen soft non tender non distended normoactive bowel sounds throughout no rebound or guarding ext bilateral pitting up to knees neuro cn2 grossly in tact motor and sensory function grossly intact in bilateral ue and symmetric nodding off during exam discharge physical exam general alert oriented and in no acute distress heent sclera anicteric poor dentition neck supple jvp low no lad appreciated lungs clear to auscultation bilaterally moving air well and symmetrically no wheezes rales or rhonchi appreciated cv regular rate and rhythm s1 and s2 clear and of good quality no murmurs rubs or gallops appreciated abdomen soft non tender non distended normoactive bowel sounds throughout no rebound or guarding ext bilateral pitting up to knees r l minimal resolving erythema rle several scabbed over excoriations neuro cn2 grossly intact motor and sensory function grossly intact in bilateral ue and symmetric pertinent results admission labs 55pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 55pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 55pm blood ptt 55pm blood glucose urean creat na k cl hco3 angap 55pm blood lipase 55pm blood albumin 55pm blood probnp imaging chest x ray low lung volumes mild cardiomegaly and central pulmonary vascular congestion right apical airspace opacity appears modestly more conspicuous as compared to the prior examination and could be further evaluated by apical lordotic views if clinically indicated chest x ray findings the previously described opacity at the right lung apex appears less conspicuous on apical lordotic views some of the abnormality is due to deformity of the right clavicular head and there may be additional bony deformity of the adjacent manubrium impression no good evidence for clinically significant pulmonary or pleural abnormality at the right apex brief hospital course undomiciled man with a history of hepatitis c opioid use disorder alcohol abuse who presented to the ed with day history of hematemesis one week history of r l bilateral lower extremity edema rib pain after sustaining rib fractures in assault and hemoptysis hematemesis vs hemoptysis patient did not give a clear history he reported vomiting up blood but while inpatient rn observed hemoptysis he reports a history of rib fractures secondary to assault he denies fevers chills weight loss night sweats because he also had concomitant r l lower extremity edema pulmonary embolism is possible pulmonary infection trauma malignancy are also possibilities i discussed this with the patient and ordered lower extremity ultrasound and cta to evaluate further the source of bleeding he left the hospital against medical advice before this could be obtained bilateral lower extremity edema r l unclear etiology as well while there is pulmonary vascular congestion on admission cxr his probnp is normal and he has no symptoms of chf apparently had recent diagnosis of cellulitis and started treatment with antibiotics prescribed at patient reports negative lenis severe onycomycosis and excoriations from scratching on bilateral lower extremities predisposing to cellulitis as above ordered lenis but patient left against medical advice before this could be obtained opioid use disorder unable to confirm methadone dose with addiction before he left against medical advice he indicates 73mg po daily patient reports ongoing daily heroin use occasionally snorting heroin despite being enrolled in methadone program social work was consulted but was unable to see him before he left against medical advice i had a frank discussion with the patient regarding his ongoing drug abuse he stated he was interested in drug rehabilitation and agreed to stay for further workup as outlined above shortly after our discussion he told his nurse he was leaving against medical advice and he walked out of the hospital before i could re assess him and have a discussion of risks medications on admission the preadmission medication list is accurate and complete methadone mg po daily unable to verify with addiction treatment where he reportedly obtains methadone discharge medications methadone mg po daily discharge disposition home discharge diagnosis opiod use disorder discharge condition left against medical advice discharge instructions left against medical advice followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies vancomycin thorazine contact metal agent attending chief complaint sore throat major surgical or invasive procedure colonoscopy on history of present illness mr is a male with a pmh of treatment native hcv polysubstance abuse heroin and benzo and homelessness who is being directly admitted for colonoscopy prep for brbpr the patient follows with pcp and dr was recently seen in for brbpr at the time he was recommended to proceed with a colonoscopy however due to his homelessness he was unable to perform the prep his pcp and dr was able to coordinate a prep for his work up on presentation the patient complaints of having a mild sore throat that started yesterday without radiation denies congestion cough or sputum production fever or chills he also has abdominal pain in the ruq which he says is chronic from his hep c in addition the patient endorsed having consumed 3x 25oz beer and half a pint of vodka hours prior to his presentation ros pertinent positives and negatives as noted in the hpi all other systems were reviewed and are negative past medical history hcv bipolar disorder opioid use disorder with active iv heroin use last used a few hours prior to admission sometimes sniffs etoh active surgical history incision drainage and packing of left forearm abscess lt tibial and rt shoulder fixation bwh social history family history unknown physical exam admission general alert and in no distress disheveled malodorous eyes anicteric pupils equally round ent ears and nose without visible erythema masses or trauma oropharynx without visible lesion erythema or exudate cv heart regular no murmur no s3 no s4 no jvd resp lungs clear to auscultation with good air movement bilaterally breathing is non labored gi abdomen soft non distended non tender to palpation bowel sounds present no hsm gu no suprapubic fullness or tenderness to palpation msk neck supple moves all extremities strength grossly full and symmetric bilaterally in all limbs bilateral pedal edema up to the knees skin no rashes or ulcerations noted neuro alert oriented face symmetric gaze conjugate with eomi speech fluent moves all limbs sensation to light touch grossly intact throughout psych pleasant appropriate affect discharge general alert and in no distress does not appear intoxicated eyes anicteric pupils equally round ent ears and nose without visible erythema masses or trauma oropharynx without visible lesion erythema or exudate cv heart regular no murmur no s3 no s4 no jvd resp lungs clear to auscultation with good air movement bilaterally breathing is non labored gi abdomen soft non distended non tender to palpation bowel sounds present no hsm gu no suprapubic fullness or tenderness to palpation msk moves all extremities strength grossly full and symmetric bilaterally in all limbs bilateral pedal edema up to the knees skin no rashes or ulcerations noted neuro alert oriented face symmetric gaze conjugate with eomi speech fluent moves all limbs sensation to light touch grossly intact throughout psych pleasant appropriate affect pertinent results admission 05pm glucose urea n creat sodium potassium chloride total co2 anion gap 05pm estgfr using this 05pm alt sgpt ast sgot alk phos tot bili 05pm lipase 05pm tot prot phosphate 05pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 05pm plt count 05pm discharge 19am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 19am blood glucose urean creat na k cl hco3 angap 05pm blood alt ast alkphos totbili brief hospital course the patient left against medical advice he expressed understanding of the risk of withdrawal if he left and had capacity to leave mr is a male with the pmh of hcv ptsd polysubstance abuse and prediabetes who presents for prep for brbpr acute active problems brbpr presented with new onset of brbpr he was admitted to complete inpatient prep colonoscopy normal except for hemorrhoids on homelessness sw consult was placed but he left ama prior to them seeing him treatment na ve hcv hx of ivdu and needle sharing ast alt slightly elevated he should be treated for hcv which he can discuss with his pcp polysubstance abuse active etoh and heroin abuse last etoh use was on the day of admission where he drank half a pint of vodka and 3x oz beers will need to remain inpatient to ensure no withdrawal in addition he continues to use heroin last use days prior to admission on methadone at the addictions treatment we attempted to call them to verify the home dose but they never called back we continued him on the supposed dose of mg methadone we wanted to keep him in the hospital to monitor for etoh withdrawal but he elected to leave against medical advice we requested sw come by to evaluate outpatient resources for relapse prevention pedal edema bilateral pedal edema could be to nutritional deficiency and alcohol abuse chronic problems ptsd prediabetes more than minutes were spent preparing this discharge medications on admission the preadmission medication list is accurate and complete albuterol inhaler puff ih q6h prn sob chlorthalidone mg po daily methadone mg po daily naloxone nasal spray mg ih once mr1 fluticasone furoate mcg actuation nasal daily discharge medications folic acid mg po daily rx folic acid mg tablet s by mouth daily disp tablet refills multivitamins tab po daily rx multivitamin tablet s by mouth daily disp tablet refills thiamine mg po daily rx thiamine hcl vitamin b1 vitamin b mg tablet s by mouth daily disp tablet refills albuterol inhaler puff ih q6h prn sob chlorthalidone mg po daily fluticasone furoate mcg actuation nasal daily methadone mg po daily naloxone nasal spray mg ih once mr1 discharge disposition home discharge diagnosis primary hemorrhoids polysubstance abuse secondary hcv discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr you were admitted to because you had blood in your stool you also were drinking alcohol we did a colonoscopy which only showed hemorrhoids which you can treat with over the counter baths and steroid cream but it does not mean you have any life threatening diseases we wanted to keep you to ensure that you didn t have any withdrawal symptoms from drinking alcohol but you elected to leave against medical advice we hope that you will seek the help you need for your alcohol use you should follow up with your primary care physician after discharge call them in the morning to schedule an appointment your care team at 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 right knee pain infection major surgical or invasive procedure explant right tka placement abx spacer history of present illness y o male with probably right knee pji here for explant right tka and placement antibiotic cement spacer with dr past medical history dyslipidemia reflux bph 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 a prevena wound vac dressing in place thigh full but soft no calf tenderness strength silt nvi distally toes warm pertinent results 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 08am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 08am blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 00am blood glucose urean creat na k cl hco3 angap 30am blood glucose urean creat na k cl hco3 angap 08am blood glucose urean creat na k cl hco3 angap 30am blood glucose urean creat na k cl hco3 angap 00am blood alt ast ld ldh alkphos totbili 08am blood alt ast alkphos totbili 00am blood calcium phos mg 30am blood calcium phos mg 08am blood calcium phos mg 30am blood calcium phos mg 00am blood crp 08am blood crp 30am blood vanco 30am blood vanco 08am blood vanco 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 cultures were taken in the or and showed coag negative staph per id recommendations he was started on iv vancomycin and ancef their final recommendations were postoperative course was remarkable for the following pod he became orthostatic with he was given 500ml bolus of iv and responded appropriately pod the patient reported right calf pain on exam a rle ultrasound was obtained and negative for a dvt a picc was placed and placement was confirmed by x ray tip is at the level of cavoatrial junction pod the patient denied any right calf tenderness on exam the prevena wound vac dressing was changed on prior to discharge he is due for a vac change on his systolic blood pressure was s he was asymptomatic he was bloused with 500cc ns his systolic blood pressure improved to s his vancomycin dose 1250mg every hours was confirmed with pharmacy and infectious disease he will be due for a vancomycin trough on please fax results to as his dose may need to be adjusted otherwise pain was controlled with a combination of iv and oral pain medications the patient received lovenox daily for dvt prophylaxis starting on the morning of pod prevena wound vac applied to right knee and changed on this will be due for a change on by the rehab facility confirmed that this can be down at the rehab facility by case manager the patient was seen daily by physical therapy labs were checked throughout the hospital course and repleted accordingly at the time of discharge the patient was tolerating a regular diet and feeling well the patient was afebrile with stable vital signs the patient s hematocrit was acceptable and pain was adequately controlled on an oral regimen the operative extremity was neurovascularly intact the patient s weight bearing status is touch down weigh bearing on the operative extremity no range of motion of right knee with knee immbolizer on at all times please use walker or crutches mr is discharged to rehab in stable condition medications on admission acetaminophen mg po q8h bupropion mg po bid aripiprazole mg po daily atorvastatin mg po daily furosemide mg po daily omeprazole mg po daily tamsulosin mg po qhs sertraline mg po daily trazodone mg po qhs prn sleep issues discharge medications docusate sodium mg po bid enoxaparin sodium mg sc daily duration weeks start tomorrow first dose first routine administration time heparin flush units ml ml iv once mr1 for picc insertion duration dose oxycodone immediate release mg po q4h prn pain senna mg po bid sodium chloride flush ml iv daily and prn line flush vancomycin mg iv q 8h acetaminophen mg po q8h aripiprazole mg po daily atorvastatin mg po daily bupropion mg po bid furosemide mg po daily omeprazole mg po daily sertraline mg po daily tamsulosin mg po qhs trazodone mg po qhs prn sleep issues discharge disposition extended care facility discharge diagnosis right knee pji 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 surgeon s 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 anticoagulation please continue your lovenox daily for four weeks to help prevent deep vein thrombosis blood clots at the end of the four weeks you may return to your normal aspirin regimen if you were taking aspirin preoperatively wound care prevena wound vac in place changed on it may remain in place for days and will due to be changed on check the wound for signs of infection such as redness or thick yellow drainage and promptly notify your surgeon of any such findings immediately once at home home iv antibiotics picc care wound care activity touchdown weight bearing on the right lower extremity use two crutches or a walker mobilize often no range of motion of the right knee knee immobilizer on right lower extremity at all times no strenuous exercise or heavy lifting until cleared picc care per protocol weekly labs draw on and send result to id rns at r n s at cbc diff chem lfts esr crp please draw a vanco trough level on and fax result to all questions regarding outpatient parenteral antibiotics should be directed to the r n s at or to the on call id fellow when the clinic is closed physical therapy touch down weight bearing rle no range of motion of right knee knee immobilizer at all times on rle treatments frequency right knee prevena wound vac last changed on wound vac due to be changed on please continue with prevena wound vac dressing until his post op visit on with pa c right picc line care per protocol 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 right knee periprosthetic joint infection major surgical or invasive procedure removal of antibiotic spacer irrigation debridement revision total knee arthroplasty on the right history of present illness year old male with known right joint infection with antibiotic spacer now status post removal of antibiotic spacer and revision total knee arthroplasty past medical history dyslipidemia reflux bph 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 aquacel dressing with scant serosanguinous drainage thigh full but soft no calf tenderness strength silt nvi distally toes warm pertinent results 22am blood hct 30am blood hgb hct 00pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood hgb hct 20am blood hgb hct 22am blood creat 00pm blood glucose urean creat na k cl hco3 angap 00am blood creat 20am blood creat 00pm blood ck cpk 00pm blood calcium phos mg 00pm blood crp blood culture blood culture routine pending inpatient blood culture blood culture routine pending inpatient tissue gram stain final tissue preliminary staphylococcus coagulase negative anaerobic culture preliminary inpatient joint fluid gram stain final fluid culture preliminary inpatient tissue gram stain final tissue final anaerobic culture preliminary inpatient tissue gram stain final tissue final anaerobic culture preliminary inpatient tissue gram stain final tissue preliminary anaerobic culture preliminary inpatient tissue gram stain final tissue final anaerobic culture preliminary inpatient brief hospital course the patient was admitted to the orthopaedic surgery service and was taken to the operating room for above described procedure please see separately dictated operative report for details the surgery was uncomplicated and the patient tolerated the procedure well patient received perioperative iv antibiotics postoperative course was remarkable for the following pod the patient was hypotensive while in bed systolics into the he was given ml bolus of lr x1 his drains were discontinued pod or cultures grew staph coag negative colony on plate id consulted they recommended discontinuing ancef and starting daptomycin labs were obtained per id request wbc hct lytes wnl ck crp esr was blood cultures x were also obtained which revealed no growth to date pod no acute events or changes in antibiotic regimen or cultures pending sensitivities to daptomycin pod infectious disease recommended weeks of iv daptomycin a picc was placed for weeks of iv antibiotics opat recommended continuing daptomycin from through otherwise pain was controlled with a combination of iv and oral pain medications the patient received aspirin mg twice daily for dvt prophylaxis starting on the morning of pod the surgical dressing will remain on until pod after surgery 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 dressing was intact the patient s weight bearing status is weight bearing as tolerated on the operative extremity with no range of motion restrictions please use walker or crutches wean as able mr is discharged to home with services in stable condition medications on admission aripiprazole mg po daily atorvastatin mg po qpm bupropion sustained release mg po bid meloxicam mg oral daily omeprazole mg po daily sertraline mg po daily sildenafil mg po daily prn night time tamsulosin mg po qhs trazodone mg po qhs prn insomnia acetaminophen mg po q6h prn pain mild fever naproxen mg po q12h prn pain moderate discharge medications aspirin ec mg po bid daptomycin mg iv q24h start date projected end date docusate sodium mg po bid gabapentin mg po tid oxycodone immediate release mg po q4h prn pain no drinking alcohol or driving while taking this medication senna mg po bid acetaminophen mg po q8h aripiprazole mg po daily atorvastatin mg po qpm bupropion sustained release mg po bid omeprazole mg po daily continue while on week course of aspirin mg twice daily sertraline mg po daily sildenafil mg po daily prn night time tamsulosin mg po qhs trazodone mg po qhs prn insomnia held meloxicam mg oral daily this medication was held do not restart meloxicam until weeks post op held naproxen mg po q12h prn pain moderate this medication was held do not restart naproxen until weeks post op discharge disposition home with service facility discharge diagnosis right knee periprosthetic joint infection discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions 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 until cleared by your physician anticoagulation please continue your aspirin mg twice daily with food for four weeks to help prevent deep vein thrombosis blood clots continue your home omeprazole to prevent gi upset if you were taking aspirin prior to your surgery take it at mg twice daily until the end of the weeks then you can go back to your normal dosing wound care please remove aquacel dressing on pod after surgery it is okay to shower after surgery after days but no tub baths swimming or submerging your incision until after your four week checkup please place a dry sterile dressing on the wound after aqaucel is removed 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 once at home home dressing changes as instructed and wound checks activity weight bearing as tolerated on the operative extremity two crutches or walker wean assistive device as able mobilize rom as tolerated no strenuous exercise or heavy lifting until follow up appointment picc care per protocol weekly labs draw on and send result to id rns at r n s at cbc diff chem lfts esr crp cpk physical therapy wbat rle romat wean assistive device as able i e crutches or walker mobilize frequently treatments frequency remove aquacel pod after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies sulfa sulfonamide antibiotics cilostazol attending chief complaint abdominal pain major surgical or invasive procedure ercp and stone extraction history of present illness ms is a woman with history of htn hld choledocholithiasis presenting with abdominal pain patient is obtained from patient and her daughter who is at the bedside patient states that pain started yesterday located in epigastum with radiation to the back was sudden in onset associated with nausea and vomiting no diarrhea fevers or chills patient has a history of gallstones for which she underwent ercp with stone removal and sphincterotomy she initially presented to there labs notable for ast alk phos t bili lipase hb wbc ua positive for bacteria and white blood cells received iv fluids and meropenem in outside hospital she was then transferred here for evaluation for ercp past medical history past medical surgical history choledocholithiasis hypertension hyperlipidemia diverticulosis social history family history father died age mother died age old age physical exam admission exam general alert and in no apparent distress eyes anicteric pupils equally round ent ears and nose without visible erythema masses or trauma oropharynx without visible lesion erythema or exudate cv heart regular no murmur resp lungs clear to auscultation with good air movement bilaterally breathing is non labored gi abdomen soft non distended minimal tenderness in the epigastric and ruq region bowel sounds present no hsm gu no suprapubic fullness or tenderness to palpation msk neck supple moves all extremities strength grossly full and symmetric bilaterally in all limbs skin no rashes or ulcerations noted neuro alert oriented face symmetric gaze conjugate with eomi speech fluent moves all limbs sensation to light touch grossly intact throughout psych pleasant appropriate affect discharge exam vitals temp po bp hr rr o2 sat o2 delivery ra general alert and in no apparent distress eyes anicteric pupils equally round cv heart rrr no edema resp lungs clear to auscultation with good air movement bilaterally breathing is non labored gi abdomen soft epigastric and ruq tenderness mild no rebound rigidity bs 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 diaphoresis neuro alert oriented face symmetric psych pleasant appropriate affect pertinent results admission labs 53am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 22am blood alt ast alkphos totbili 53am blood alt ast alkphos totbili imaging ct a p bid p increased biliary ductal dilation mixed intermediate density and calcified filling defect in the distal common bile duct most consistent with a partially calcified gallstone or group of gallstones there are additional intermediate density noncalcified filling defects resting dependently within the gallbladder correlation with clinical symptoms and lfts is suggested diffuse colonic diverticulosis without gross evidence of diverticulitis bilateral low grade upj obstructions ercp stone extracted microbiology urine culture negative urine culture e coli blood cultures x no growth to date discharge labs 53am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 53am blood glucose urean creat na k cl hco3 angap 53am blood alt ast alkphos totbili 53am blood mg woman with history of hypertension hyperlipidemia choledocholithiasis presenting with choledocholithiasis sepsis resolved cholangitis choledocholithiasis patient with history of choledocholithiasis presenting with abdominal pain found to have leukocytosis tachycardia transaminitis hyperbilirubinemia and imaging evidence cbd dilatation patient started on meropenem at outside hospital transitioned to ceftriaxone and metronidazole blood cultures were negative urine culture at osh grew e coli 100k organisms she was eventually transitioned to ciprofloxacin to complete a five day course ercp was performed with sphincteroplasty stone removal and relief of obstruction lfts downtrended after this procedure patient was able to advance diet without a problem lipase was within normal limits she will follow up with her pcp within one week of discharge anemia baseline unknown though hemoglobin at no evidence of active bleeding hemoglobin stable here with some dilutional effect from iv fluids she may need further work up for chronic anemia as an outpatient by her pcp hypertension continued home metoprolol and nifedipine lisinopril was initially held and restarted on discharge hyperlipidemia home statin will be held for now given elevated lfts transitions of care follow up she will follow up with her pcp within one week of discharge home statin will be held for now given elevated lfts and should be restarted if these normalize code status dnr dni contacts hcp surrogate and communication updated by me medications on admission the preadmission medication list is accurate and complete lisinopril mg po daily nifedipine extended release mg po daily aspirin mg po daily atorvastatin mg po qpm metoprolol tartrate mg po bid discharge medications acetaminophen mg po q6h prn pain mild fever ciprofloxacin hcl mg po q24h rx ciprofloxacin hcl mg tablet s by mouth q24h disp tablet refills aspirin mg po daily lisinopril mg po daily metoprolol tartrate mg po bid nifedipine extended release mg po daily held atorvastatin mg po qpm this medication was held do not restart atorvastatin until a doctor tells you to discharge disposition home discharge diagnosis choledocholithiasis sepsis possible urinary tract infection discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms it was a pleasure caring for you during your recent hospitalization you came to the hospital with abdominal pain further testing showed that your bile duct was obstructed and you underwent ercp to relieve the obstruction you are now being discharged it is important that you continue to take your medications as prescribed and follow up with the appointments listed below good luck followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies pepcid sulfasalazine metronidazole azathioprine attending chief complaint fever major surgical or invasive procedure lumbar puncture history of present illness h o crohn s disease and recent hospitalization for treatment of pan colitis with initiation of cyclosporine and use of prednisone 40mg daily presented to the ed with fever high unspecified throbbing headache and neck stiffness when i interviewed her she was confused and could not further characterize the details of her illness such as duration as she kept repeating that headache was present for months and could not tell me how high and when her fever started she denies abdominal pain or bloody stools currently she could no complete a 13pt ros given confusion and difficulties with sharing details of her illness but she denies new rash weakness trouble with movement past medical history reviewed details listed in past clinic notes confirmed h o crohn s and latent tb w patient latent tb s p treatment in ileocolonic fistulizing crohn s dx in now on low dose pre and anti tnf previously tx with methotrexate h o remicade infusion reaction hospitalized rx cyclosporine and steroids hypertension social history family history no family history of crohn s physical exam temp ra awake confused inattentive often answers questions with odd answer that does not pertain to question being asked ie responds to question about year by saying after i had asked her questions about orientation to month incorrectly selects rather than repeats certain phrases such as months ago moves facial features symmetrically no visual field defects pupils contrict from to 2mm equally i think there is some proptosis of her l eye r oral candidiasis w white plaque on tongue clear breath sounds without wheeze rapid loud s1 and s2 across precordium no audible distinct murmurs no cervical or neck adenopathy able to flex neck forward and back without difficulty no focal abdominal tenderness no appreciable hepatomegaly no joint effusions no visible rash to face back extremities full motor strength against resistance in all extremities did not test gait she performed poorly with clock draw task see attached well appearing not confused fluent speech eating food and walking independently no meningismus calm and cooperative clear lungs soft non tender abd pertinent results 16pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 50am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 50am blood glucose urean creat na k cl hco3 angap 50am blood alt ast alkphos totbili 22am blood cyclspr 50am blood hcg 23pm blood lactate cxr no focal infiltrate 05am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 05am blood glucose urean creat na k cl hco3 angap 50am blood alt ast alkphos totbili 22am blood cyclspr 23pm blood lactate hsv pcr neg pm csf spinal fluid add on request for viral culture on gram stain final no polymorphonuclear leukocytes seen no microorganisms seen this is a concentrated smear made by cytospin method please refer to hematology for a quantitative white blood cell count fluid culture preliminary no growth enterovirus culture preliminary no enterovirus isolated hematology analysis wbc rbc polys lymphs monos clear and colorless cell differential pink and hazy supernatant clear chemistry chemistry totprot glucose with crohn s disease who is immunosuppressed with ongoing use of cyclosporine and prednisone who was hospitalized for evaluation of fever and leukocytosis on admission she appeared septic as well as encephalopathic she rapidly improved and had no ongoing signs of encephalopathy within 16hrs of admission ultimately no source for her leukocytosis and fevers were found but it was suspected that it was a viral infection id and gi consulted fever sepsis she underwent infectious work up including lumbar puncture her csf profile was unremarkable other than slightly elevated protein and mildly elevated rbc but was not suggestive of bacterial meningitis her hsv pcr was negative and enterovirus culture was negative she received empiric broad spectrum antibiotics vanco ceftriaxone ampicillin and acyclovir until her cultures and hsv returned negative her serum crypto antigen was negative she did not have diarrhea or abdominal pain and her cdiff was negative wbc improved she had decrease in all cell lines consistent with dilutional effect as she received 3liters ivf on her first day of hospitalization crohn s restarted cyclosporine on discharge continued prednisone 40mg and bactrim ppx gi consulted and during her admission cyclosporine was held and it was deemed to be safe to restart this therapy for her crohn s disease on discharge she was counseled on its effects and toxicities during last admission when it was started htn elevated bps during admission continued on hctz gave a dose of amlodipine on but when pharmacy alert noted that it interacts with cyclosporine she will not continue amlodipine on discharge i am most concerned by the possibility of an encephalitis given her seemingly acutely confused state fever meningismus seen in the ed with csf studies that do not clearly suggest acute bacterial meningitis i am keeping a broad differential for bacterial viral and even mycobacterial pathogens h o latent tb as causative pathogens i understand cyclosporine can cause cns toxicity but she has been on stable dose and her level was and this likely would not cause fever and leukocytosis i have already spoken with id who will consult urgently i have ordered hsv pcr to be performed on her csf though there is insufficient fluid to also perform enterovrius pcr and vzv pcr there does not appear to be clinical evidence for pulmonary or gi infections given lack of respiratory or gi symptoms and the presence of a clear xray while influenza is negative if she develops cough or other symptoms we can obtain nasal swab for full resp viral panel management diagnostic hsv pcr mri brain with contrast stat id consult treatment acyclovir 700mg iv q8h empiric antibitoics for bacterial meningitis to be continued until discussed with id and we observe csf cultures ceftriaxone 2000mg iv q12h iv vancomycin 1000mg q12h held off on addition of ampicillin for now supportive care with additional fever and anti pyretic agents crohn s disease i already spoke with gi team who knows her and will follow she does seem to have acute confusion as compared with their recent clinical exams continue prednisone 40mg daily hold cyclosporine now htn hctz 25mg daily heparin sc bid full code presumed contacted son listed in as contact but no answer she will need ongoing hospitalization 48hrs to sort out the cause and to appropriately treat the above acute illness medications on admission the preadmission medication list is accurate and complete cyclosporine neoral modified mg po q12h acetaminophen w codeine tab po q6h prn pain cetirizine mg po daily nystatin oral suspension ml po qid prn thrush fluticasone propionate nasal spry nu bid prednisone mg po daily sulfameth trimethoprim ss tab po daily lactaid lactase unit oral prn discharge medications cetirizine mg po daily fluticasone propionate nasal spry nu bid prednisone mg po daily rx prednisone mg tablet s by mouth once a day disp tablet refills sulfameth trimethoprim ss tab po daily rx sulfamethoxazole trimethoprim mg mg tablet s by mouth once a day disp tablet refills hydrochlorothiazide mg po daily cyclosporine neoral modified mg po q12h rx cyclosporine modified mg capsule s by mouth twice a day disp capsule refills lactaid lactase unit oral prn acetaminophen w codeine tab po q6h prn pain discharge disposition home discharge diagnosis acute viral illness nos encephalopathy resolved likely infectious crohn s disease hypertension discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were hospitalized for evaluation of fever and confusion you underwent testing with lumbar puncture mri and lab work that did not show evidence of bacterial or viral infection you still may have had a viral infection that got better with time take cyclosporine as prescribed as well as prednisone and bactrim f u with your gi doctor next week if your blood pressure remains elevated your doctors need to add on another blood pressure pill followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies pepcid sulfasalazine metronidazole azathioprine remicade attending chief complaint weakness abdominal discomfort hematochezia weight loss major surgical or invasive procedure none history of present illness ms is a pleasant with hx htn hemorrhoids crohn s for which she has been on various regimens but currently was controlled on methotrexate every other week no previous bowel surgeries last admission for fever r o meningitis who presents with decreasing h h mild weakness generalized abd discomfort occasional bloody stools most recent days ago and wks ago and 15lb weight loss in months per review of her records she was last hospitalized for her crohns in at that time it was recommended that she undergo total colectomy but the pt declined and ultimately was stabilized on cyclosporine and prednisone she required tpn for a brief period at that time she has since been followed by and at the time of her last visit in she was doing well with only mild anemia at however given intolerance of oral iron iv iron infusions was recommended at that time her methotrexate was decreased from weekly to every other week regarding her recent presentation pt states that she was initially brought to urgent care on by her son who thought that she didn t look well and was concerned about her wt loss she was found to be anemic with crit of and they recommended that she go to the ed however she didn t present until today pt states that she has been feeling at and abd pain is no worse than recent consisting of chronic diffuse mild pain x m in regards to the bloody bms she had blood bms weeks ago which resolved within hrs she had some small blood on tp yesterday with wiping but has not otherwise noticed dark or bloody stools no v d or loose stools subjective fever earlier this week has resolved finally pt endorses l chest and axillary pain occurring in a discrete line x weeks often occurs at rest not exertional lasts minutes sharp reproducible not present currently pain is typically improved with raising her l arm no concurrent sob in the ed initial vitals were ra vitals remained stable and she remained afebrile while she was in the ed labs were notable for ua with trace leuks few bacteria she was given oxycodone hctz folic acid and amlodipine labs were notable for troponin x1 lactate crp cxr showed currently she feels well pain stable nausea no v d bloody stools no recent sick contects no recent travel ros notable for chronic constipation which is stable on mirilax suppository no dysuria or frequency nocturia night had black stools in the past but none recently review of systems per hpi denies chills night sweats recent weight loss or gain denies headache sinus tenderness rhinorrhea or congestion denies cough shortness of breath denies chest tightness palpitations denies vomiting diarrhea no recent change in bowel or bladder habits no dysuria denies arthralgias or myalgias pt ros otherwise negative past medical history per chart confirmed with pt crohn s disease currently on methotrexate every other week h o remicade infusion reaction hospitalized rx cyclosporine and steroids allergic rhinitis occ bronchitis hypertension diet controlled diabetes lactose intolerance on lactate positive ppd treated with inh x months and rifaximin for m in no longer on tx arthritis knees ankle and l shoulder currently receiving hypertension hx iron def anemia on folic acid x2 has not yet gotten iron infusion has on tylenol social history family history per chart confirmed with pt and updated no family history of crohn s htn breast ca physical exam admission vitals ra constitutional alert oriented no acute distress moves comfortably around the room heent sclera anicteric mmm oropharynx clear eomi perrl neck supple jvp not elevated no lad cv tachycardic regular rhythm normal s1 s2 no murmurs rubs gallops respiratory clear to auscultation bilaterally no wheezes rales rhonchi gi soft mild diffuse ttp non distended bowel sounds present no organomegaly no rebound or guarding gu no foley rectal small external hemorrhoids no stool in vault ext warm well perfused no cce neuro aaox3 cnii xii and strength grossly intact skin no rashes or lesions msk point ttp on palpation of chest in area where pt c o cp discharge vitals ra gen nad lying in bed moving around well eyes eomi sclerae anicteric ent mmm op clear cv rrr no murmur pulm normal effort no accessory muscle use lungs cta gi soft nt nd bs skin no visible rash no jaundice neuro aaox3 fluent speech no facial droop psych full range of affect pertinent results 35pm urine hours random 35pm urine hours random 35pm urine uhold hold 35pm urine gr hold hold 35pm urine color yellow appear clear sp 35pm urine blood neg nitrite neg protein glucose neg ketone neg bilirubin neg urobilngn neg ph leuk tr 35pm urine rbc wbc bacteria few yeast none epi 35pm urine mucous many 07pm lactate 00pm glucose urea n creat sodium potassium chloride total co2 anion gap 00pm estgfr using this 00pm alt sgpt ast sgot ld ldh alk phos tot bili dir bili indir bil 00pm lipase 00pm ctropnt 00pm albumin calcium phosphate magnesium 00pm crp 00pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 00pm neuts lymphs monos eos basos im absneut abslymp absmono abseos absbaso 00pm plt count 00pm ptt 00pm 00pm ret aut abs ret cxr no pna or effusion no acute process my read ekg no st t changes nsr sigmoidoscopy there were a few pseudopolyps in the sigmoid colon the rest of the mucosa to the splenic flexure appeared normal except for some scarring adjacent to the anus there was a large anal tag otherwise normal sigmoidoscopy to splenic flexure at 70cm discharge labs 45am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 45am blood glucose urean creat na k cl hco3 angap 00am blood calcium phos mg with crohn s disease presenting with abdominal discomfort weakness weight loss and occasional hematochezia as well as atypical chest pain worsening anemia concerning for slow gi bleed and possible crohn s flare c diff colitis causing abdominal pain weight loss hematochezia subjective fevers initial concern for flare of crohn s uncontrolled crohn s disease but sxs have been stable for the last months despite decrease in methotrexate dosing abd pain is mild no clear recent bloody stools as episode days ago sounds more like hemorrhoidal bleed than true gi bleed she was found to be c diff positive and was started on po vanco 125mg q6 for days she had improvement in her symptoms prior to the c diff result coming back she had been placed on iv solumedrol for possible flair that was stopped once the c diff came back positive gi felt all symptoms consistent with c diff and no need for colonoscopy microcytic anemia acute blood loss anemia h h baseline hct likely blood loss anemia given report of knife injury with significant bleeding and no gi bleeding while in the hospital she received units of prbc in the hospital with stable h h following she was given a dose of iv iron as her iron studies were consistent with iron defiency anemia chest pain ekg with no concerning changes for ischemia neg trop atypical and reproducible on exam suggestive of msk in etiology improved with monitoring hypertension elevated in the ed s p amlodipine and hctz with improvement in sxs continued home meds ha continued prn tylenol gerd continued prn tums allergies continued cetirizine fluticasone chronic arthritis pain continued percocet will hold off on lidocaine patch as pt is unable to get as an outpt contact daughter greater than minutes was spent in care coordination and counseling on the day of discharge medications on admission the preadmission medication list is accurate and complete acetaminophen dose is unknown po q8h prn ha calcium carbonate dose is unknown po tid prn dyspepsia methotrexate ml iv every weeks mo polyethylene glycol g po daily prn constipation fluticasone propionate nasal spry nu daily lactaid lactase unknown oral unknown amlodipine mg po daily lactobacillus combination no unknown oral daily oxycodone acetaminophen 5mg 325mg tab po bid prn pain cetirizine mg po daily hydrochlorothiazide mg po daily folic acid mg po daily lidocaine ointment appl tp as needed lidocaine patch ptch td qam discharge medications acetaminophen mg po q8h prn pain amlodipine mg po daily calcium carbonate mg po tid prn dyspepsia cetirizine mg po daily fluticasone propionate nasal spry nu daily folic acid mg po daily hydrochlorothiazide mg po daily oxycodone acetaminophen 5mg 325mg tab po bid prn pain polyethylene glycol g po daily prn constipation lactaid lactase tab oral frequency is unknown lactobacillus combination tab oral daily lidocaine ointment appl tp as needed methotrexate ml iv every weeks mo vancomycin mg oral q6h duration days rx vancomycin mg capsule s by mouth every hours disp capsule refills discharge disposition home with service facility discharge diagnosis c diff colitis anemia 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 in the hospital you were admitted for evaluation you were found to be anemic and received blood with good response you were found to have c diff colitis and were started on antibiotics and you improved you will need to complete a day course of antibiotics please take your medications as directed and follow up with your pcp and gastroenterologist followup instructions

name unit no admission date discharge date date of birth sex f service neurology allergies pepcid sulfasalazine metronidazole azathioprine remicade ceftin attending chief complaint seizure major surgical or invasive procedure history of present illness eu critical is a woman with crohn s disease and htn who presents after an event concerning for seizure two hours prior to admission she called her significant other and was mumbling he says that it sounded like she were drinking because she kept mumbling and was not making sense he told her that he would talk to her later she was apparently coming home from school very stressed out has a paper due tomorrow and if she does not pass an exam she will not be able to graduate she was standing at the kitchen sink roommate came in the room and noticed that she was odd and staring into space and not talking roommate came in different times to check on her and after the third time the roommate heard a thud she had fallen at the sink and a glass fell from her hand her extremities were extended and shaking and her whole body was turning to the left side her eyes were open and rolled back mother thought episode lasted seconds but others say less than min ems called and pt had another episode that lasted 1min when they arrived all episodes self resolved and did not require medication blood glucose in the 180s sbp in 110s with hr in and pin point pupils she was brought to no tongue biting unclear if there were any incontinence never had episodes like this before of note this would be her third christmas in the hospital per mother pt is not back at baseline past medical history per chart confirmed with pt crohn s disease currently on methotrexate every other week h o remicade infusion reaction hospitalized rx cyclosporine and steroids allergic rhinitis occ bronchitis hypertension diet controlled diabetes lactose intolerance on lactate positive ppd treated with inh x months and rifaximin for m in no longer on tx arthritis knees ankle and l shoulder currently receiving hypertension hx iron def anemia on folic acid x2 has not yet gotten iron infusion has on tylenol social history family history per chart confirmed with pt and updated no family history of crohn s htn breast ca physical exam admission exam vitals hr bp rr sao2 ra general nad heent ncat cervical collar in place 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 to self and women s and when asked year says it is unable to relate history inattentive follows simple commands speech is fluent with short sentences intact repetition naming intact to high frequency objects no paraphasias perseverates no dysarthria cranial nerves perrl brisk vf full to number counting eomi no nystagmus 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 asterixis mild postural tremor in lue delt bic tri ecr io ip quad ham ta gas c5 c5 c7 c6 t1 l2 l3 l5 l4 s1 l r reflexes bic tri quad gastroc l r plantar response flexor bilaterally pectoralis jerk and cross adductors present bilaterally beats of clonus bilaterally sensory no deficits to light touch throughout coordination no dysmetria with finger to nose testing bilaterally gait deferred discharge exam pertinent results 13am comments green top 13am lactate 45am glucose urea n creat sodium potassium chloride total co2 anion gap 45am estgfr using this 45am calcium phosphate magnesium 45am wbc rbc hgb hct mcv mch mchc rdw rdwsd 45am plt count 05pm urine hours random 05pm urine hours random 05pm urine ucg negative 05pm urine gr hold hold 05pm urine bnzodzpn neg barbitrt neg opiates neg cocaine neg amphetmn neg oxycodn neg mthdone neg 05pm urine color straw appear clear sp 05pm urine blood neg nitrite neg protein glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg 05pm urine rbc wbc bacteria few yeast none epi 05pm urine hyaline 05pm urine mucous rare 20pm lactate 08pm glucose urea n creat sodium potassium chloride total co2 anion gap 08pm estgfr using this 08pm alt sgpt ast sgot alk phos tot bili 08pm albumin calcium phosphate magnesium 08pm asa neg ethanol neg acetmnphn neg bnzodzpn neg barbitrt neg tricyclic neg 08pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 08pm neuts monos eos basos im absneut abslymp absmono abseos absbaso 08pm plt count eeg impression this is an abnormal eeg as it demonstrates the presence of a single electrographic seizure without obvious clinical correlate originating from left frontotemporal regions consistent with an active focus of cortical irritability in this region in addition there are abundant left frontally predominant sharp waves presenting as continuous runs of slow periodic discharges 3hz primarily during sleep confirming local cortical irritability there are no other abnormalities noted in her record during wakefulness or sleep there are three accidental pushbutton activations mri mrv impression slightly irregular area of dural based enhancement in the anterior interhemispheric fissure adjacent to the left straight gyrus measuring up to x mm with adjacent edema of the left straight orbital gyri as described favored to represent infection particularly given adjacent mild bony irregularity of the fovea ethmoidalis possibly fungal in this patient with a history of crohn s disease with immunosuppression dural inflammatory pseudotumor would be the next most likely etiology meningioma is considered unlikely though possible minimal areas of white matter signal abnormality in a configuration most suggestive of chronic small vessel ischemic disease no dural venous sinus thrombosis mild paranasal sinus opacification as described brief hospital course is a right handed woman with past medical history significant for crohn s disease who presents after events concerning for seizures she was started on cveeg and one electrographic seizure was captured on eeg overnight she was also noted to have a left orbital frontal hypodensity on her ct scan she was started on seizure prophylaxis with 1000mg of keppra bid she underwent a mri mrv to better characterize the left sided frontal hypodensity in addition to ruling out other possible focal pathology including a sinus venous thrombosis which she would be at increased risk for given her crohn s disease mri mrv showed dural based enhancement and edema of the left straight orbital gyri concerning for infectious process ent and neurosurgery were consulted ent exam did not reveal any abnormalities the decision was made to repeat her imaging in weeks before we proceeding with a biopsy of note the patient was noted to have a cystic lesion in her kidney which should be followed up with ultrasound in year she was also noted to have a pfo pulmonary hypertension and pulmonary aneurysms which should be addressed in pulmonary and cardiology clinic we were unable to arrange these follow ups do to the holiday weekend medications on admission the preadmission medication list is accurate and complete amlodipine mg po daily diclofenac sodium topical bid prn fluticasone propionate nasal spry nu bid folic acid mg po daily hydrochlorothiazide mg po daily lidocaine topical bid prn methotrexate mg sc 1x week 6ml sc once weekly by visiting nurse oxycodone acetaminophen 5mg 325mg tab po bid prn pain moderate polyethylene glycol g po daily prn constipation tramadol mg po tid prn pain moderate acetaminophen mg po q8h prn pain mild calcium carbonate mg po daily prn heartburn cetirizine mg po daily glycerin supps supp pr prn constipation lactaid lactase unit oral daily prn probiotic b breve l acid l rham s thermo br l acidophilus l rhamnosus br l acidophilus bif animalis br l rhamn acidophilus br lactobacillus comb no br lactobacillus combination no br lactobacillus combo no billion cell oral daily discharge medications levetiracetam mg po bid rx levetiracetam keppra mg tablet s by mouth twice a day disp tablet refills acetaminophen mg po q8h prn pain mild amlodipine mg po daily calcium carbonate mg po daily prn heartburn cetirizine mg po daily diclofenac sodium apl topical bid prn rash fluticasone propionate nasal spry nu bid folic acid mg po daily glycerin supps supp pr prn constipation hydrochlorothiazide mg po daily lactaid lactase unit oral daily prn lidocaine topical bid prn methotrexate mg sc 1x week 6ml sc once weekly by visiting nurse oxycodone acetaminophen 5mg 325mg tab po bid prn pain moderate polyethylene glycol g po daily prn constipation probiotic b breve l acid l rham s thermo br l acidophilus l rhamnosus br l acidophilus bif animalis br l rhamn acidophilus br lactobacillus comb no br lactobacillus combination no br lactobacillus combo no billion cell oral daily tramadol mg po tid prn pain moderate discharge disposition home discharge diagnosis seizures discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear were admitted to for evaluation of episodes that were concerning for seizures were placed on cveeg overnight and we captured an electrographic seizure were started on keppra mg twice a day also underwent mri mrv of your brain and it showed and area of inflammation in an area of your brain which was likely the cause of your seizures please discuss with your primary care doctor the need to set up pulmonary and cardiology follow up appointments please continue to take your medications as described have follow up appointments scheduled as below it was a pleasure taking care of best your team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies pepcid sulfasalazine metronidazole azathioprine remicade ceftin attending chief complaint vision loss major surgical or invasive procedure none history of present illness with crohn s on mtx newly dx d seizures with brain masses of unknown significance and recent ed visit for l orbital cellulitis presents with sudden onset of monocular vision loss weeks ag o the patient was seen in the ed for week of progressive blurry vision her eye exam demonstrated increased intraocular pressure and mild proptosis ct orbit showed fat stranding and she was discharged on clindamycin for orbital cellulitis the patient had been doing well and awoke this am with left eye vision loss patient states she is able to see some in the periphery of her left eye she has pain with extraoccular movements she went to see her eye doctor who did a dilated exam and sent her to for further eval the patient had been having occasional subjective fevers last fever days ago no chest pain or dyspnea no neck pain no difficulty swallowing she was seen by ophtho in the ed the ophthalmic exam is normal aside from a previously noted apd in the left eye the mri orbits brain demonstrates what appears to be a left perineuritis there are no clinical signs of orbital cellulitis aside from mild proptosis of the left globe optic perineuritis is often associated with inflammatory conditions ie orbital pseudotumor sarcoid and is treated with steroids often times with improvement in vision the problem is the prior concern that the previously noted brain lesion is an indolent infection such as fungus given this concern i think the benefit of improved vision with steroids is overruled by the potentially fatal complication of unmasking the potential fungal infection in the brain with steroids neurology agreed with evaluation seen by ent as well to eval for mucor they did a fiberoptic exam which was reassuring also seen by neurosurgery who felt that benefit from steroids outweighed risk of infection decision was made to start steroids in the ed initial vs were ra exam notable for nad left sided proptosis pain with eom of left eye pupils dilated fundoscopic blurred disc l eye no erythema rrr no mrg ctab visual acuity patient does not have glasses with her od os n a occular pressure per outpatient eye doctor today l cn iii intact labs showed wbc hgb hematuria imaging showed mri orbit there is minimal increased signal and enhancement within the retro bulbar fat on the left series image and series image which given differences in modality is similar compared to the prior ct in addition there is increased enhancement of the left orbital nerve compared to the right series image the left orbital nerve may be slightly expanded compared to the right again these findings likely represent postseptal orbital cellulitis as suggested on the prior ct no acute abnormalities within the visualized brain parenchyma mild paranasal sinus disease is re demonstrated please refer to the final report for full details received percocet vanc levoquin benadryl transfer vs were ra neurology ophthalmology ent and neurosurgery were consulted on arrival to the floor patient confirms the above story she clarifies that she was previously having fevers unmeasured may be hot flashes but none today or yesterday she also states her vision improved to baseline after clinda but then when she awoke on day of presentation suddenly had central vision loss she currently denies f c n v sob cp dizzy abd pain had some r sided tenderness earlier constipation diarrhea endorses continued central vision loss she had some itching earlier with percocet that resolved with benadryl vaginal bleeding is minimal past medical history per chart confirmed with pt crohn s disease currently on methotrexate every other week h o remicade infusion reaction hospitalized rx cyclosporine and steroids allergic rhinitis occ bronchitis hypertension diet controlled diabetes lactose intolerance on lactate positive ppd treated with inh x months and rifaximin for m in no longer on tx arthritis knees ankle and l shoulder currently receiving hypertension hx iron def anemia on folic acid x2 has not yet gotten iron infusion has on tylenol social history family history per chart confirmed with pt and updated no family history of crohn s htn breast ca physical exam admission physical exam vs po general nad pleasant heent at nc eomi w tenderness on l l proptosis mild periorbital swelling neck supple no lad no thyroid nodules palpated heart rrr murmur lungs ctab no wheezes rales rhonchi breathing comfortably without use of accessory muscles abdomen nondistended nontender in all quadrants no rebound guarding extremities no cyanosis clubbing or edema neuro a ox3 moving all extremities with purpose skin warm and well perfused no excoriations or lesions no rashes discharge physical exam vitals ra general alert oriented no acute distress heent sclerae anicteric mmm oropharynx clear neck supple jvp not elevated no lad resp clear to auscultation bilaterally no wheezes rales ronchi cv regular rate and rhythm normal s1 s2 no murmurs rubs gallops abd soft gu no foley ext warm well perfused pulses no clubbing cyanosis or edema neuro visual field testing improved almost resolved proptosis on left resolving pertinent results admission labs 00pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00pm blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 00pm blood plt 00pm blood ptt 00pm blood glucose urean creat na k cl hco3 angap micro lyme pending hiv pending imaging mri brain with orbits diffuse enhancement surrounding the left optic nerve with adjacent retrobulbar fat stranding these findings are suggestive of perineuritis with differential considerations including inflammatory process such as sarcoid postseptal cellulitis is considered less likely paranasal sinus disease as above additional chronic findings as described above discharge labs 45am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30am blood glucose urean creat na k cl hco3 angap brief hospital course ms is a yo woman with crohn s disease on methotrexate and recently diagnosed seizure disorder as well abnormal mri brain findings who presented with vision loss and mri findings of perineuritis she was seen by the neurology neurosurgery ent and ophthalmology in the ed she was also seen by the infectious disease doctors her symptoms were thought to be due to either perineuritis from an inflammatory process vs partially treated post septal cellulitis she improved with steroids and antibiotics steroid course to be determined by ophthalmology team vision loss perineuritis most likely etiology is inflammatory process vs infectious opthomology recommended steroids mg daily with taper to be determined as outpatient id was consulted and felt comfortable with steroids but also recommend unasyn while in house and then augmentin x weeks on discharge out of concern for partially treated pre septal cellulitis id felt there was lower index of suspicion for fungal disease to explain current presentation b glucan galactomanan hiv and lyme were ordered and pending at time of discharge patient s vision was much improved at time of discharge she will follow with optho scheduled prior to discharge this week and id will contact her for a follow up appointment nasal mucosa management ent was consulted in the ed and recommended the following which she received in house an ent appointment was not made at discharge but the patient was called and given the number to follow with ent as an outpatient saline nasal spray flonase sprays each nostril bid afrin sprays tid for days following saline rises crohn s patient reported that she had not been taking methotrexate at home because she was worried about the cancer risk and equates the methotrexate with her new brain lesions her gastroenterologist asked that her methotrexate be restarted which was recommended to the patient however there is an interaction between augmentin and methotrexate so it was recommended that she hold the methotrexate until she complete her antibiotic course anemia vaginal bleeding stbale throughout stay on morning of discharge had a drop in h h but on repeat h h was back to baseline suggesting a lab error she was continued on medroxyprogesterone acetate tabs bid through chronic issues hx of cribiform plate mass f u imaging with improvement neurosurgery f u as outpatient leptomeningeal enhancement new noted on mri culture reported final report on was also negative serum rpr tox antibody were negative id discussed with patient the importance of biopsy for definitive diagnosis but she declined htn well controlled continued dilt seizure disorder continued keppra transitional issues abx augmentin through steroid course to be determined by optho if patient is on steroids weeks would initiate her on bactrim prophylaxis methotrexate was restarted per gi recs but patient was unwilling to take it would recommend discussing with her outpatient gastroenterologist however should hold methotrexate while on augmentin should schedule id follow up pending at time of discharge pending labs b glucan galactomannan lyme titer and hiv medications on admission the preadmission medication list may be inaccurate and requires futher investigation albuterol inhaler puff ih q6h prn sob wheeze azelastine mcg nasal bid voltaren diclofenac sodium topical q6h prn pain diltiazem extended release mg po daily fluticasone propionate nasal spry nu daily folic acid mg po daily levetiracetam mg po bid lidocaine ointment appl tp bid methotrexate mg sc 1x week we oxycodone acetaminophen 5mg 325mg tab po bid prn pain severe polyethylene glycol g po daily prn contstipation tramadol mg po tid prn pain severe medroxyprogesterone acetate mg po bid beano alpha d galactosidase unit oral asdir calcium carbonate mg po prn indigestion cetirizine mg po daily diphenhydramine mg po qhs prn allergy discharge medications amoxicillin clavulanic acid mg po q12h duration days rx amoxicillin pot clavulanate augmentin mg mg daily by mouth twice a day disp tablet refills prednisone mg po daily rx prednisone mg tablet s by mouth daily disp tablet refills albuterol inhaler puff ih q6h prn sob wheeze azelastine mcg nasal bid beano alpha d galactosidase unit oral asdir calcium carbonate mg po prn indigestion cetirizine mg po daily diclofenac sodium sodium topical q6h prn pain diltiazem extended release mg po daily diphenhydramine mg po qhs prn allergy fluticasone propionate nasal spry nu daily folic acid mg po daily levetiracetam mg po bid lidocaine ointment appl tp bid medroxyprogesterone acetate mg po bid methotrexate mg sc 1x week we oxycodone acetaminophen 5mg 325mg tab po bid prn pain severe polyethylene glycol g po daily prn contstipation tramadol mg po tid prn pain severe discharge disposition home with service facility discharge diagnosis primary diagnosis perineuritis post septal cellulitis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms it was a pleasure taking care of you at why was i here you had blurred vision you were seen by many different doctors and got steroids and antibiotics you got better what should i do when i get home it is very important to take all your medicines everyday if you do not want to take your methotrexate please let dr followup instructions

name unit no admission date discharge date date of birth sex f service neurology allergies pepcid sulfasalazine metronidazole azathioprine remicade ceftin attending chief complaint positive igm serum lyme major surgical or invasive procedure none history of present illness ms is a year old woman with a history of crohn s disease on methotrexate with recent admission to bi acute onset left eye vision loss found to have an abnormal mri consistent with left perioptic neuritis which has improved and she now returns with a positive lyme igm ms reports a history of blurred vision and pain in her left eye which was present for the past month she presented to the ed three weeks ago with left eye pain and was found to have left eye proptosis on exam ct showed fat stranding around the eye and she was given a diagnosis of orbital cellulitis and started on clindamycin which improved the blurry vision on she awoke with vision loss in the left eye and presented to ed initial neurologic exam showed l eye proptosis and apd with a loss of vision in the right hemifield of the left eye she then underwent mri brain and orbits which showed diffuse enhancement of the optic nerve sheath on the left consistent with left perioptic neuritis neurology was consulted who recommended id involvement she was treated initially with vancomycin and cipro and then narrowed to augmentin she also began prednisone 60mg daily on she reports improvement in her vision since starting prednisone she followed up with dr in neuro ophthalmology most recently in clinic on visual acuity was documented initially as only to hand movements in the left eye and then after steroids etiology was thought to be secondary an underlying autoimmune etiology though work up thus far has been negative she had routine follow up with her pcp who sent off lyme which turned out to be positive on she was referred back to the ed to be worked up for possible cns lyme on my visit in the past week since she has been discharged she states that her vision is now back to baseline her pain with extraocular movements has resolved she denies headache she did note that days prior she had blurry vision for about hour but then improved to baseline she states her plan for prednisone and antibiotics were extended for an additional weeks she is very concerned about how she may have obtained lying she denies exposure to wounds or tick bites she denies rashes she is wondering whether her cat was the reason for her exposure but her cat is a house cat since discharge her only complaint is her chronic knee and ankle pain which she has previously attributed to crohn s of note she was admitted to the neurology service in with events concerning for seizure and was found to have left frontal seizures with secondary generalization left frontal flair hyperintensity anterior skullbase dural enhancement discontinuity of the ethmoid plate on the left no clear sinus mass all new from mri lp was notable for wbc protein normal glucose etiology was unknown and given her clinical stability patient deferred biopsy she was treated with keppra 1g bid for her seizures and they have been well controlled since then ros notable for chronic joint pains but no tick bites or rashes she does note indigestion that improved with baking soda as well as initial nausea when taking prednisone past medical history per chart confirmed with pt crohn s disease currently on methotrexate every other week h o remicade infusion reaction hospitalized rx cyclosporine and steroids allergic rhinitis occ bronchitis hypertension diet controlled diabetes lactose intolerance on lactate positive ppd treated with inh x months and rifaximin for m in no longer on tx arthritis knees ankle and l shoulder currently receiving hypertension hx iron def anemia on folic acid x2 has not yet gotten iron infusion has on tylenol social history family history per chart confirmed with pt and updated no family history of crohn s htn breast ca physical exam admission physical exam vitals t p r bp sao2 ra general awake cooperative nad heent nc at no scleral icterus mmm no lesions noted in oropharynx neck supple no carotid bruits pulmonary ctabl no r r w cardiac rrr nl s1s2 no m r g abdomen soft nt nd bs no masses or organomegaly noted extremities no c c e bilaterally skin no rashes or lesions noted neurologic 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 pt was able to name both high and low frequency objects able to read without difficulty 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 left eye proptosis perrl to 2mm and brisk eomi without nystagmus vff to confrontation no red desaturation unable to visualize fundi bilaterally v facial sensation intact to light touch vii l eye proptosis no facial droop facial musculature symmetric viii hearing intact to finger rub bilaterally ix x palate elevates symmetrically xi strength in trapezii and scm bilaterally xii tongue protrudes in midline motor normal bulk tone throughout no pronator drift bilaterally no adventitious movements such as tremor noted no asterixis noted delt bic tri wre ffl fe io ip quad ham ta l r sensory no deficits to light touch pinprick cold sensation vibratory sense proprioception throughout no extinction to dss dtrs bi tri pat ach l r plantar response was flexor bilaterally coordination no intention tremor no dysdiadochokinesia noted no dysmetria on fnf or hks bilaterally gait good initiation narrow based normal stride and arm swing romberg absent discharge physical exam vitals t p r bp sao2 ra general awake cooperative nad heent nc at no scleral icterus mmm no lesions noted in oropharynx neck supple no carotid bruits pulmonary ctabl no r r w cardiac rrr nl s1s2 no m r g abdomen soft nt nd bs no masses or organomegaly noted extremities no c c e bilaterally skin no rashes or lesions noted neurologic 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 pt was able to name both high and low frequency objects able to read without difficulty 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 left eye proptosis perrl to 2mm and brisk eomi without nystagmus vff to confrontation no red desaturation unable to visualize fundi bilaterally v facial sensation intact to light touch vii l eye proptosis no facial droop facial musculature symmetric viii hearing intact to finger rub bilaterally ix x palate elevates symmetrically xi strength in trapezii and scm bilaterally xii tongue protrudes in midline motor normal bulk tone throughout no pronator drift bilaterally no adventitious movements such as tremor noted no asterixis noted delt bic tri wre ffl fe io ip quad ham ta l r sensory no deficits to light touch pinprick cold sensation vibratory sense proprioception throughout no extinction to dss dtrs bi tri pat ach l r plantar response was flexor bilaterally coordination no intention tremor no dysdiadochokinesia noted no dysmetria on fnf or hks bilaterally gait deferred pertinent results 35pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 35pm blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 35pm blood ptt 25am blood ptt 35pm blood glucose urean creat na k cl hco3 angap 00am blood glucose urean creat na k cl hco3 angap 35pm blood alt ast alkphos totbili 35pm blood albumin calcium phos mg 00am blood calcium phos mg 15pm urine color straw appear clear sp 15pm urine blood neg nitrite neg protein neg glucose neg ketone neg bilirub neg urobiln neg ph leuks neg 08am cerebrospinal fluid csf tnc rbc polys 08am cerebrospinal fluid csf totprot glucose 08am cerebrospinal fluid csf borrelia burgdorferi antibody index for cns infection pnd 08am cerebrospinal fluid csf angiotensin converting enzyme pnd 08am cerebrospinal fluid csf csf hold test am csf spinal fluid source lp csf cytology pending gram stain final no polymorphonuclear leukocytes seen no microorganisms seen this is a concentrated smear made by cytospin method please refer to hematology for a quantitative white blood cell count fluid culture preliminary no growth am blood lyme lyme igg pending lyme igm pending pm blood culture blood culture routine pending pm urine site clean catch final report urine culture final cfu ml mri brain and orbits interval decrease in left perioptic enhancement and retro orbital fat stranding suggestive of perineuritis stable to decreased enhancement along the interhemispheric fissure and the inferior left orbital gyrus no evidence of infarction or new abnormal enhancement cxr neg brief hospital course ms is a year old woman with a history of crohn s disease on methotrexate with left perioptic neuritis and leptomeningial enhcancement seen on prior neuroimaging that responded to steroids augmentin she had refused biopsy in past admissions symptomatically she is much improved since starting the steroids and her visual acuity is bilaterally with residual left eye proptosis only she was admitted to neurology as her serum igm came back positive for lyme unclear if perioptic neuritis related to lyme or due to other pathology such as inflammatory vs neoplastic completed lp on and sent csf for further testing such as csf lyme cytology ace csf studies notable for notable for whites rbc normal protein and glucose cytology pending serum and csf repeat serum lyme pending at time of discharge an mri brain orbits showed no interval change we also recommended biopsy to further evaluate and assess her underlying brain lesions however patient declined patient wanted to be discharged and stated she will return if she requires iv antibiotics neurology perioptic neuritis lumbar puncture performed cell count wbc rbc protein nl glucose nl lyme cytology continued current antibiotics augmentin continued prednisone 60mg daily x weeks lyme igm positive if csf lyme positive then start iv ceft will need desensitization and picc line if repeat serum lyme positive then start doxycycline id consulted f u outpatient seizures continued keppra cv htn continued diltiazam pulm continued albuterol prn gi crohns held methotrexate as there is an interaction with augmentin heme anemia menorrhagia h h trended continued medroxyprogesterone medications on admission the preadmission medication list is accurate and complete albuterol inhaler puff ih q6h prn sob wheeze diltiazem extended release mg po daily folic acid mg po daily levetiracetam mg po bid lidocaine ointment appl tp bid medroxyprogesterone acetate mg po bid methotrexate mg sc 1x week we polyethylene glycol g po daily prn contstipation prednisone mg po daily azelastine mcg nasal bid beano alpha d galactosidase unit oral asdir calcium carbonate mg po prn indigestion cetirizine mg po daily diphenhydramine mg po qhs prn allergy oxycodone acetaminophen 5mg 325mg tab po bid prn pain severe tramadol mg po tid prn pain severe amoxicillin clavulanic acid mg po q12h diclofenac sodium sodium topical q6h prn pain discharge medications albuterol inhaler puff ih q6h prn sob wheeze amoxicillin clavulanic acid mg po q12h duration days atovaquone suspension mg po daily azelastine mcg nasal bid beano alpha d galactosidase unit oral asdir calcium carbonate mg po prn indigestion cetirizine mg po daily diclofenac sodium sodium topical q6h prn pain diltiazem extended release mg po daily diphenhydramine mg po qhs prn allergy folic acid mg po daily levetiracetam mg po bid lidocaine ointment appl tp bid medroxyprogesterone acetate mg po bid methotrexate mg sc 1x week we oxycodone acetaminophen 5mg 325mg tab po bid prn pain severe polyethylene glycol g po daily prn contstipation prednisone mg po daily tramadol mg po tid prn pain severe discharge disposition home discharge diagnosis inflammatory process discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms you were admitted to with a positive lyme blood test given concern that this may be related to you underlying unknown neurologic diagnosis a lumbar puncture was recommended to evaluate for lyme in the nervous system additionally a lumbar puncture was recommended to further work up the lesions in your brain specifically to look for evidence of cancer cells results of which are pending but so far the preliminary tests are benign you were seen by the id doctors and your lyme testing in the blood was repeated and lyme was tested in your spinal fluid and the results are pending if the spinal fluid returns positive we will have you come back to the hospital to start iv antibiotics you should continue on prednisone and augmentin to treat the inflammation around the optic nerve and follow up with ophtho and neurology please be sure to return to the hospital should we find positive test results it was a pleasure taking care of you your neurologists followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies pepcid sulfasalazine metronidazole azathioprine remicade ceftin aspirin attending chief complaint brbpr major surgical or invasive procedure none history of present illness ms is a female hx seizure disorder crohn s disease followed by dr cva with residual arm weakness presents for evaluation of lower gi bleeding pt states that she has known crohn s disease and is followed by dr been with ongoing lower gi bleeding for the past days pt notes that she has had cups of red blood per rectum 2x day x days and x over the past one day pt notes having some associated lower abdominal cramping but notes no nausea vomiting fevers chills chest pain sob cough sore throat uti symptoms no travel no sick contacts pt is not on anticoagulation no dizziness or lightheadedness pt notes that a sigmoidoscopy was performed on the day of presentation outpatient workup by gi for bleeding which showed diverticulosis an erythematous patch with mild edema without bleeding biopsy taken and pt referred for admission given evidence of active bleeding in the ed pt was hemodynamically stable cbc chemistries crp notable for hgb was crp pt w o any symptoms pt admitted for additional evaluation and treatment past medical history per chart confirmed with pt crohn s disease currently on methotrexate every other week h o remicade infusion reaction hospitalized rx cyclosporine and steroids allergic rhinitis occ bronchitis hypertension diet controlled diabetes lactose intolerance on lactate positive ppd treated with inh x months and rifaximin for m in no longer on tx arthritis knees ankle and l shoulder currently receiving hypertension hx iron def anemia on folic acid x2 has not yet gotten iron infusion has on tylenol social history family history per chart confirmed with pt and updated no family history of crohn s htn breast ca physical exam admission exam exam vitals afebrile and vital signs stable see eflowsheet general alert and in no apparent distress eyes anicteric pupils equally round ent ears and nose without visible erythema masses or trauma oropharynx without visible lesion erythema or exudate cv heart regular no murmur no s3 no s4 no jvd resp lungs clear to auscultation with good air movement bilaterally breathing is non labored gi abdomen soft non distended non tender to palpation bowel sounds present no hsm gu no suprapubic fullness or tenderness to palpation msk neck supple moves all extremities strength grossly full and symmetric bilaterally in all limbs skin no rashes or ulcerations noted neuro alert oriented face symmetric gaze conjugate with eomi speech fluent moves all limbs sensation to light touch grossly intact throughout psych pleasant appropriate affect cbc wbc h h plt bmp k cl co2 bun cr discharge exam general alert and in no apparent distress eyes anicteric pupils equally round ent nc at mmm cv heart regular no murmur no s3 no s4 no jvd resp lungs clear to auscultation with good air movement bilaterally breathing is non labored gi abdomen soft nd bs no tenderness to palpation gu no suprapubic fullness or tenderness to palpation msk neck supple moves all extremities strength grossly full and symmetric bilaterally in all limbs skin no rashes or ulcerations noted neuro alert oriented face symmetric gaze conjugate with eomi speech fluent moves all limbs sensation to light touch grossly intact throughout psych pleasant appropriate affect discharge labs hgb stable at bmp unchanged pertinent results 20am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 35am blood glucose urean creat na k cl hco3 angap 35am blood crp 15pm blood ptt 15pm blood lipase 15pm blood ctropnt 15pm blood albumin calcium phos mg iron 15pm blood caltibc ferritn trf discharge labs significant for stable hemoglobin at 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt brief hospital course this is a year old female with a history of crohn s disease followed by dr hypertension seizure disorder and cva who comes in from endoscopy suite for evaluation of lower gi bleeding brbpr acute blood loss anemia chron s disease pt presents for evaluation of a brbpr of day duration she had a sigmoidoscopy outpatient to evaluate for source of bleeding which showed internal hemorrhoids diverticulosis and bleeding throughout colon without source identified outpatient gi doctor referred patient in for inpatient monitoring and further work up with colonoscopy on arrival patient was hds and hgb was down from on she was started on a ppi and evaluated by inpatient gi team patient reported reluctance in undergoing a colonoscopy and requested to instead have follow up with her gi physician gi consult team felt this was reasonable given stable blood counts she did have one additional episode on of blood mixed in with stool and bright blood on tp that patient felt was smaller in quantity in comparison to episodes at home patient was transitioned to oral pantoprazole and started on iron on discharge given iron deficiency on blood work fe tibc ferritin source of bleeding remained unclear and is likely chron s flare vs internal hemorrhoids she was instructed to call her outpatient gi physician to set up follow up appointment within the next days and counseled on red flag return precautions chronic medical problems seizure disorder c h keppra htn home verapamil held out of c f gib discharged with instruction to restart medication given stable hgb and bps transitional issues source of brbpr remained unclear however appeared to be decreased in quantity during hospitalization please follow up sigmoidoscopy biopsies from patient instructed to call her outpatient gi physician for follow up within day patient started on pantoprazole mg daily as she felt symptom relief with this medication found to be iron deficient during hospitalization hgb stable throughout hospitalization discharged with prescription for ferrous sulfate mg po every other day minutes spent on discharge planning and care coordination medications on admission the preadmission medication list is accurate and complete levetiracetam mg po bid cetirizine mg po daily diltiazem extended release mg po daily diphenhydramine mg po qhs oxycodone acetaminophen 5mg 325mg tab po q6h prn pain severe fleet enema saline aily prn constipation discharge medications pantoprazole mg po q24h cetirizine mg po daily diphenhydramine mg po qhs levetiracetam mg po bid oxycodone acetaminophen 5mg 325mg tab po q6h prn pain severe diltiazem extended release mg po daily discharge disposition home discharge diagnosis bright red blood per rectum anemia chron s disease discharge condition stable independent and ambulatory discharge instructions ms you were sent into the hospital by your gi doctor with bloody stool of day duration after having a sigmoidoscopy in their clinic during your hospitalization your blood counts remained stable and you did have some further stool with blood but it seemed to be decreased in comparison to the bleeding you had at home prior to coming in we started you on a medication to help with acid production in your stomach in the case that your bleeding was caused by an ulcer you should follow up with your gi doctor for further work up we wish you all the best your care team followup instructions

name unit no admission date discharge date date of birth sex f service orthopaedics allergies adhesive tape namenda attending chief complaint right knee pain major surgical or invasive procedure right total knee replacement by md history of present illness year old female with right knee jra osteoarthritis which has failed conservative management and has elected to proceed with a left total knee replacement on past medical history pmh anxiety dementia hx of bcca hx of c diff s p stool transplant hypothyroid juvenile rheumatoid arthritis diverticulosis panic disorder hx of dvt interstitial cystitis pshx l tha hysterectomy cataract surgery excision of bcca on nose cholectomy 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 00pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 40am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 20am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00pm blood plt 40am blood plt 30am blood plt 20am blood plt 40am blood glucose urean creat na k cl hco3 angap 30am blood glucose urean creat na k cl hco3 angap 20am blood glucose urean creat na k cl hco3 angap 30am blood mg 20am blood calcium phos mg 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 pod patient was triggered for hypotension with sbp 120s down to while working with patient reported some dizziness with nausea and emesis she was administered iv zofran for nausea with improved relief patient s bp improved to 140s 60s when reclined back in chair she was also administered 500ml bolus of iv fluids and her magnesium was repleted geriatrics was also consulted for co management of care which they recommended switching cholestyramine to prn dosing given that patient is on colace senna bowel regimen to prevent constipation while on narcotics pod magnesium level improved to pod patient s hematocrit was she was given a unit of blood her post transfusion hematocrit was stable and she was cleared for discharge home 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 on pod and 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 ms is discharged to home with services in stable condition medications on admission atenolol mg po daily cholestyramine gm po daily donepezil mg po daily econazole topical apply to top and bottom of feet and between toes 2x a day finasteride mg po daily halobetasol propionate topical apply to rash twice a day weeks per month hydroxychloroquine sulfate mg po daily lorazepam mg po q6h prn anxiety losartan potassium mg po daily sertraline mg po take tablets by mouth every morning acetaminophen mg po x a day as needed pain vitamin d dose is unknown po daily advil ibuprofen diphenhydramine cit mg oral tablet by mouth as needed lactobacillus acidophilus mg million cell oral daily discharge medications docusate sodium mg po bid enoxaparin sodium mg sc daily oxycodone immediate release mg po q4h prn pain moderate do not drink alcohol or drive while taking med senna mg po bid acetaminophen mg po q8h cholestyramine gm po daily prn diarrhea atenolol mg po daily donepezil mg po daily econazole topical apply to top and bottom of feet and between toes 2x a day finasteride mg po daily halobetasol propionate topical apply to rash twice a day weeks per month lactobacillus acidophilus mg million cell oral daily lorazepam mg po q6h prn anxiety losartan potassium mg po daily sertraline mg po take tablets by mouth every morning held advil ibuprofen diphenhydramine cit mg oral tablet by mouth as needed this medication was held do not restart advil until you complete your course of lovenox injections held hydroxychloroquine sulfate mg po daily this medication was held do not restart hydroxychloroquine sulfate until at least weeks post op and requires clearance by your surgeon discharge disposition home with service facility discharge diagnosis right knee juvenile rheumatoid arthritis 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 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 at your follow up appointment in two weeks once at home home dressing changes as instructed wound checks activity weight bearing as tolerated on the operative extremity mobilize rom as tolerated no strenuous exercise or heavy lifting until follow up appointment physical therapy wbat rle romat mobilize frequently wean from assistive devices when appropriate treatments frequency daily dressing changes as needed for drainage inspect incision daily for erythema drainage ice and elevation of operative limb remove staples and replace with steri strips at follow up visit in clinic followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies morphine indocin nafcillin attending chief complaint shortness of breath major surgical or invasive procedure none history of present illness ms is a woman with a history of hfref ef in atrial fibrillation t2dm htn and possibly a recent tia who presents with days of progressive shortness of breath fatigue and altered mental status she was admitted to from for a possible tia at that time mri and other diagnostic tests were negative so she was discharged to on her dig was held and was decreased at that hospitalization but per reports she was taking both at rehab on her daughter visited her at rehab and noticed that she was confused and somnolent a urine culture was collected which eventually grew e coli the nursing staff encouraged ms to drink lots of fluid and her mental status improved by however for the past days she has become increasingly short of breath and she developed a 2l o2 requirement she has also had more confusion per her daughter she has had increased orthopnea and lower extremity swelling l r during this time no chest pain nausea vomiting abdominal pain dysuria urinary frequency or diarrhea in the ed initial vitals were 2l nasal cannula exam notable for crackles in lle edema in lle ekg afib with hr left axis deviation rbbb lafb with twi in i avl unchanged from baseline on labs notable for probnp cr baseline u a with few bacteria mod imaging showed cxr with edema patient was given lasix 40mg ivx1 at 5pm ceftriaxone 1g x1 vitals on transfer nasal cannula on the floor patient feels well she endorses shortness of breath but no chest pain or palpitations she is able to answer all questions appropriately and she does not feel confused she does feel that her legs are more swollen than usual no new medicines and no changes to her lasix dose recently ros on review of systems denies any prior history of stroke deep venous thrombosis pulmonary embolism bleeding at the time of surgery myalgias joint pains cough hemoptysis black stools or red stools denies recent fevers chills or rigors denies exertional buttock or calf pain all of the other review of systems were negative cardiac review of systems is notable for absence of chest pain palpitations syncope or presyncope past medical history cardiac risk factors diabetes hypertension cardiac history cabg none percutaneous coronary interventions cardiac catheterization at in showing small vessel disease cardiac cath in showing two vessel disease without any intervention pacing icd none atrial fibrillation on coumadin coronary artery disease schf with ef other past medical history history of non hodgkin s lymphoma multinodular goiter chronic low back pain s p hysterectomy s p bilateral knee replacements s p bilateral eye surgery social history family history diabetes grandmother died of mi at father mi in mother died before her of heart condition that was undiagnosed physical exam admission physical vs on ra admission weight kg no clear dry weight gen well appearing elderly woman in nad heent ncat no scleral icterus perrl eomi moist mucous membranes neck jvp 12cm cv irregular rate rhythm no m r g pulm normal work of breathing on 2lnc bilateral crackles in lung bases no wheezes abd soft nt nd no suprapubic tenderness normal bowel sounds gu no foley ext warm dp pulses edema on left trace edema on right neuro cn ii xii intact strength in upper lower extremities able to say day of the week backwards a ox3 discharge physical vss temp bp rr sats ra i o wt gen well appearing elderly woman in nad sitting up in chair heent ncat no scleral icterus cv irregularly irregular rate and rhythm no murmurs gallops rubs pulm normal work of breathing bibasilar crackles stable from yesterday s exam no wheezing abd soft nt nd normoactive bowel sounds ext warm dp pulses no edema in the lower extremities bilaterally pertinent results admission labs 35pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 35pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 35pm blood ptt 35pm blood glucose urean creat na k cl hco3 angap 35pm blood alt ast ld ldh ck cpk alkphos totbili 35pm blood ck mb ctropnt probnp 35pm blood albumin calcium phos mg 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 other important labs 35pm blood digoxin 54am blood ctropnt 38pm blood ck mb ctropnt 55am blood ck mb ctropnt 04pm blood ck mb ctropnt imaging chest x ray moderate pulmonary edema moderate cardiomegaly no evidence pneumonia oppler no evidence of deep venous thrombosis in the left lower extremity veins echocardiogram the left atrial volume index is severely increased the right atrium is moderately dilated the estimated right atrial pressure is mmhg left ventricular wall thicknesses are normal the left ventricular cavity is mildly dilated overall left ventricular systolic function is severely depressed lvef secondary to akinesis of the inferior and posterior walls and hypokinesis of the rest of the left ventricle doppler parameters are most consistent with grade ii moderate left ventricular diastolic dysfunction the right ventricular free wall thickness is normal the right ventricular cavity is moderately dilated with severe global free wall hypokinesis fractional area change the diameters of aorta at the sinus ascending and arch levels are normal there are focal calcifications in the aortic arch the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened moderate mitral regurgitation is seen due to acoustic shadowing the severity of mitral regurgitation may be significantly underestimated there is mild pulmonary artery systolic hypertension significant pulmonic regurgitation is seen there is no pericardial effusion compared with the prior study images reviewed of contractile dysfunction of both ventricles is now severe studies dipyridamole nuclear stress test interpretation year old female with a history of chf ef cad with probable old inferior mi atrial fibrillation dmii htn and hld referred for nuclear study for evaluation of shortness of breath after serial negative cardiac markers the patient was infused with mg kg min of dipyridamole over minutes the test was terminated due to completion of the protocol the patient reported no chest neck back or arm pain baseline nssttw s in the setting of rbbb persisted through infusion and recovery no significant st segment changes noted ekg showed atrial fibrillation with rare vpb s hemodynamic response to dipyridamole infusion was appropriate the patient was infused with mg of aminophylline to reverse effects of dipyridamole impression no anginal or significant st segment changes noted nuclear report sent separately moderate fixed inferior wall perfusion defect more severe at the apical aspect partial reversibility seen in is no longer appreciated worsened left ventricular systolic function since with reduction of ejection fraction to moderate left ventricular enlargement micro blood cultures ngtd as of urine culture final escherichia coli cfu ml presumptive identification cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h escherichia coli cfu ml second morphology cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h sensitivities mic expressed in mcg ml escherichia coli escherichia coli ampicillin r r ampicillin sulbactam i i cefazolin s s cefepime s s ceftazidime s s ceftriaxone s s ciprofloxacin r r gentamicin s s meropenem s s nitrofurantoin s s piperacillin tazo s s tobramycin s s trimethoprim sulfa s s brief hospital course with hfref ef afib on warfarin t2dm htn recent tia who presented with altered ms fatigue doe she was admitted to a few weeks ago with sx concerning for tia mri was negative thus d c on to rehab on was confused somnolent u a ecoli but not treated and was given fluid thus became increasingly sob orthopnea leg edema admitted to cardiology underwent iv diuresis to euvolemia and was transitioned to torsemide qam qpm had stress test to eval for reversible ischemia several fixed defects were found treated with ctx x5d for uti afib is anticoagulated with warfarin due to subtherapeutic inr and chads2 she was bridged with heparin back to her warfarin inr therapeutic at discharge also presented with clopidogrel on her medication list in addition to asa warfarin full details are not available but suspect prescribed at for tia it was discontinued as her inpatient cardiology service and outpatient cardiologist dr that the bleeding risk of triple ac exceeded the expected benefit acute issues acute on chronic systolic heart failure exacerbation acute on chronic exacerbation possibly due to untreated uti at rehab troponins negative bnp in s most likely ischemic known hx 2vd no reversible defects found on stress test this admission discharge weight kg preload torsemide 40mg qam 20mg qpm nhbk metoprolol succinate xl mg po daily afterload losartan potassium uptitrated to mg po ng daily contractility digoxin daily device none for now plan to see ep as outpatient pmibi without reversible ischemia urinary tract infection treated with a course of ceftriaxone ending pt did not have fevers or dysuria at discharge atrial fibrillation chads2 rc metoprolol succinate 100mg daily ac warfarin bridged with heparin gtt this admit for inr warfarin therapy managed by chronic resolved issues ckd on admission cr was which appears to be her baseline stable at prior to discharge medications were renally dosed t2dm on lantus qam qhs with hiss in house asthma continued home albuterol inh gerd continued ppi chronic pain continued home gabapentin 100mg po bid fractionated home percocet to acetaminophen mg po ng tid with oxycodone immediate release mg po ng q4h prn pain vitamin d deficiency continued home vitamin d unit po daily transitional issues discharge weight kg started spironolactone recommends discharge to home with and family assist need to see ep as outpatient for consideration of device therapy for her heart failure as she has no reversible changes seen on stress test next labs chemistry inr inr managed by completed therapy for uti medications on admission the preadmission medication list is accurate and complete aspirin mg po daily digoxin mg po every other day furosemide mg po daily losartan potassium mg po daily metoprolol succinate xl mg po daily pantoprazole mg po q24h atorvastatin mg po qpm albuterol inhaler puff ih q6h prn shortness of breath docusate sodium mg po bid nitroglycerin sl mg sl prn chest pain percocet oxycodone acetaminophen mg oral tid prn pain potassium chloride meq po daily senna mg po daily vitamin d unit po daily levemir units breakfast levemir units bedtime insulin sc sliding scale using hum insulin gabapentin mg po tid warfarin mg po daily16 discharge medications spironolactone mg po daily rx spironolactone mg one half tablet s by mouth daily disp tablet refills torsemide mg po qam am rx torsemide mg tablet s by mouth every morning disp tablet refills torsemide mg po qpm pm rx torsemide mg tablet s by mouth every afternoon disp tablet refills digoxin mg po daily rx digoxin mcg one half tablet s by mouth daily disp tablet refills losartan potassium mg po daily rx losartan mg tablet s by mouth daily disp tablet refills metoprolol succinate xl mg po daily rx metoprolol succinate mg tablet s by mouth daily disp tablet refills albuterol inhaler puff ih q6h prn shortness of breath aspirin mg po daily atorvastatin mg po qpm docusate sodium mg po bid gabapentin mg po tid levemir units breakfast levemir units bedtime insulin sc sliding scale using hum insulin nitroglycerin sl mg sl prn chest pain pantoprazole mg po q24h percocet oxycodone acetaminophen mg oral tid prn pain potassium chloride meq po daily hold for k senna mg po daily vitamin d unit po daily warfarin mg po 6x week warfarin mg po 1x week mo discharge disposition home with service facility discharge diagnosis primary diagnosis acute on chronic systolic heart failure exacerbation secondary diagnosis coronary artery disease urinary tract infection atrial fibrillation hypertension diabetes discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms it was a pleasure taking care of you during your stay at you came to the hospital because you were having shortness of breath and confusion you were found to have fluid overload most likely due to a urine infection we treated you with diuretics to remove excess fluid and your breathing improved an ultrasound of your heart showed the pumping function of your heart is decreased a stress test did not show any areas that could be fixed by procedures that restore blood flow we also treated you with antibiotics for a urinary tract infection please take all of your medications every day and weigh yourself every morning call md if weight goes up more than lbs we wish you the your medical team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies morphine indocin nafcillin attending chief complaint dyspnea chest pain major surgical or invasive procedure none history of present illness with a history of hfref infarct related ef cad atrial fibrillation t2dm htn who presents with complaint of chest pain and dyspnea patient states that over the last several days she has felt more tired with decreased appetite and progressively worsening lower extremity edema patient states that this morning around 9am she was sitting down when she had sudden onset of chest pain described as chest non radiating she states that pain has decreased somewhat but is still present and has been fairly constant since onset she has felt progressively more short of breath over the past few days as well she has had orthopnea and a dry cough she denies fever chills nausea vomiting of note pt was seen in the ed two days ago for left hand pain thought due to gout attempt at wrist aspiration yielded a dry tap she was prescribed colchicine past medical history infarct related systolic chf ef dm htn cad cath at in showing small vessel disease cardiac cath in showing two vessel disease without any intervention atrial fibrillation gout non hodgkin s lymphoma multinodular goiter chronic low back pain s p hysterectomy s p bilateral knee replacements s p bilateral eye surgery osa on cpap social history family history diabetes grandmother died of mi at father mi in mother died before her of heart condition that was undiagnosed physical exam admission physical examination vs 2lnc weight kg general well developed well nourished in nad oriented x3 mood affect appropriate heent normocephalic atraumatic sclera anicteric perrl eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthelasma neck supple jvp elevated to jawline cardiac pmi located in intercostal space midclavicular line irregular rhythm normal s1 s2 no murmurs rubs or gallops no thrills or lifts lungs no chest wall deformities or tenderness diffuse crackles to bilateral shoulder blades abdomen soft non tender non distended no hepatomegaly no splenomegaly extremities warm well perfused pitting edema to knees bilaterally skin no significant skin lesions or rashes pulses distal pulses palpable and symmetric discharge physical exam vitals hr 100s 120s 60s 70s rr ra weight kg general chronically ill appearing elderly female sitting in chair heent nc at sclerae anicteric op clear neck jvp elevated to 9cm h2o at degrees lungs lungs ctab breathes somewhat deliberately but speaking full sentences no w r r cv rrr no m g r abdomen nontender nondistended nabs ext no pitting wwp l wrist rom limited by pain ttp 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 ptt 20am blood glucose urean creat na k cl hco3 angap 50pm blood k 20am blood ck cpk 50pm blood alt ast ld ldh alkphos totbili 20am blood ck mb ctropnt probnp 50pm blood ck mb ctropnt 50pm blood albumin mg 38pm blood k 53pm blood lactate discharge labs 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 microbiology none imaging cxr moderate pulmonary edema with cardiomegaly superimposed pneumonia cannot be excluded in the appropriate clinical setting tte the left atrium is mildly dilated no left atrial mass thrombus seen excluded by transesophageal echocardiography no atrial septal defect is seen by 2d or color doppler the estimated right atrial pressure is mmhg left ventricular wall thicknesses are normal the left ventricular cavity is mildly dilated with severe hypokinesis of the septum and inferior walls and mildl hypokinesis of the remaining segments biplane lvef left ventricular cardiac index is depressed l min m2 no intraventricular thrormbus is seen there is no ventricular septal defect the right ventricular cavity is mildly dilated with moderate global free wall hypokinesis the diameters of aorta at the sinus ascending and arch levels are normal 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 there is no systolic prolapse moderate to severe mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion impression mildly dilated biventricular cavity sizes with regional and global systolic dysfunction c w multivessel cad or other diffuse process moderate to severe mitral regurgitation mild pulmonary artery systolic hypertension compared with the prior study images reviewed of the findings are similar brief hospital course with h o ischemic chf ef cad afib on apixaban dm2 on insulin htn who presents with chest pain and dyspnea admitted for acute on chronic systolic chf acute on chronic systolic chf patient presented w dyspnea volume overload on cxr elevated jvp probnp above prior values 3000s unclear precipitant as denies dietary indiscretion missed meds or other illness aside from gout wrist pain tte similar to prior lvef mild biventricular dilation severe lv hypokinesis of the septum and inferior walls and mild hypokinesis of the remaining segments mr mild pulmonary htn troponin elevated likely demand in setting of acute exacerbation and it trended down during admission diuresed well with iv lasix bid transitioned to torsemide mg bid continued home losartan started imdur mg daily hydralazine mg tid and restarted spironolactone mg daily for afterload reduction continued home metoprolol succinate but increased the dose to mg bid chest pain type nstemi on admission patient had chest pain associated with mild troponinemia without ekg changes thought to most likely be demand ischemia from chf exacerbation troponin peaked at and she did not continue to have chest pain or discomfort likely demand ischemia due to chf exacerbation cad history of vessel cad left main proximal and lad proximal w diffuse dz confirmed on cath at had previous cath with small vessel disease last nuclear stress test with moderate fixed inferior wall defect continued home metoprolol losartan aspirin and atorvastatin wrist pain likely gout has chronic back and knee pain on percocet at home with history of crystal proven gout in given 8mg colchicine and dry tap in ed prior to admission on continued to have significant pain and swelling on admission improved with colchicine 6mg bid and tylenol mg tid uric acid consistent with prior levels consider starting uric acid lowering agent after acute flare iddm morning levemir 44u qam was decreased to 34u qam for borderline fasting blood sugars in the and her pm dose was decreased from 14u to 10u continued sliding scale humalog atrial fibrillation continued home apixaban metop succinate digoxin ckd likely multifactorial from hypertension and diabetes no evidence of nephrology f u arranged hld continued atorvastatin 40mg qhs osa used home cpap machine transitional issues torsemide increased to 40mg bid discharge weight kg lbs discharge cr started imdur mg daily hydralazine mg tid and spironolactone mg daily increased metoprolol succinate dose from 100mg once daily to 75mg bid started colchicine mg bid for gout can be stopped once acute flare resolves consider uric acid lowering agent after acute flare discharged with rolling walker and home decreased insulin dosing in house as detailed above please monitor closely as outpatient and adjust as necessary contact daughter hcp cell phone code status full confirmed medications on admission the preadmission medication list is accurate and complete atorvastatin mg po qpm oxycodone acetaminophen mg oral tid apixaban mg po bid losartan potassium mg po daily metoprolol succinate xl mg po daily aspirin mg po daily senna mg po bid docusate sodium mg po bid cyanocobalamin mcg po daily vitamin d unit po daily levemir units breakfast levemir units dinner insulin sc sliding scale using hum insulin torsemide mg po qam torsemide mg po qpm potassium chloride meq po daily gabapentin mg po tid digoxin mg po daily pantoprazole mg po q24h discharge medications colchicine mg po bid rx colchicine mg tablet s by mouth twice a day disp tablet refills hydralazine mg po tid rx hydralazine mg tablet s by mouth three times a day disp tablet refills isosorbide mononitrate extended release mg po daily rx isosorbide mononitrate mg tablet s by mouth daily disp tablet refills spironolactone mg po daily rx spironolactone mg tablet s by mouth daily disp tablet refills levemir units breakfast levemir units dinner insulin sc sliding scale using hum insulin metoprolol succinate xl mg po bid rx metoprolol succinate toprol xl mg tablet s by mouth twice a day disp tablet refills torsemide mg po bid rx torsemide mg tablet s by mouth twice a day disp tablet refills apixaban mg po bid aspirin mg po daily atorvastatin mg po qpm cyanocobalamin mcg po daily digoxin mg po daily docusate sodium mg po bid gabapentin mg po tid losartan potassium mg po daily oxycodone acetaminophen mg oral tid pantoprazole mg po q24h senna mg po bid vitamin d unit po daily outpatient physical therapy rolling walker dx chf icd i50 px good months discharge disposition home with service facility discharge diagnosis acute on chronic systolic heart failure chest pain type nstemi wrist pain gout atrial fibrillation iddm 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 came to the hospital because you were short of breath and had too much fluid built up in your body you got iv medicine called lasix and you got rid of the extra fluid your breathing improved and you did not need oxygen anymore you also started medicine called colchicine for gout in your wrist you should take this until you feel better and then talk to your doctor about starting a medicine called allopurinol to prevent gout flares from happening please see below for changes in your medicines and your follow up appointments please weigh yourself every morning call dr office at if weight goes up more than pounds in one day or pounds in one week it was a pleasure caring for you and we wish you the your cardiology team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies morphine indocin nafcillin attending chief complaint chest pain major surgical or invasive procedure none history of present illness ms is an year old woman with a pmh of cad afib sleep apnea who is presenting with chest pain she has a history of angina for which she takes isosorbide she describes sudden onset sharp left chest pain without radiation consistent with her prior anginal symptoms which happened at approximately she took no additional medications for this she also experienced shortness of breath in the context of this chest pain she was feeling well this morning without fever chills sweats abdominal pain or chest pain denies vomiting chest pain is sharp over her anterior left chest without radiation and without associated diaphoresis no exacerbating or alleviating factors no exercise intolerance per her husband she is walking around the house comfortably of note patient was hospitalized from with chest pain and heart failure exacerbation after an acs rule out her chest pain was eventually attributed to her heart failure she was treated with iv lasix she was discharged on an increased dose of torsemide from 40mg qam 20mg qpm to 40mg bid and was started on imdur mg daily hydralazine mg tid in addition to her home metoprolol and spironolactone after discharge her cr increased from on discharge to at that time her dose of torsemide was again decreased to 40mg qam 20mg qpm in the ed initial vitals were ra exam notable for no leg swelling mild tenderness over his soft tissue of lateral right calf and distal thigh labs notable for cbc wbc hgb hct plt lytes ptt inr trop t no imaging was done cardiology was consulted and recommended admission to service patient was given po aspirin mg ivf ns ml ordered vitals prior to transfer ra upon arrival to the floor patient reports that she continues to have chest pain saying it is her typical chest pain that comes and goes otherwise states that she feels tired review of systems per hpi point ros reviewed and negative unless stated above in hpi past medical history infarct related systolic chf ef dm htn cad cath at in showing small vessel disease cardiac cath in showing two vessel disease without any intervention atrial fibrillation gout non hodgkin s lymphoma multinodular goiter chronic low back pain s p hysterectomy s p bilateral knee replacements s p bilateral eye surgery osa on cpap social history family history diabetes grandmother died of mi at father mi in mother died before her of heart condition that was undiagnosed physical exam admission physical exam vital signs hr bp rr ra general tired appearing elderly woman sleeping in bed lying flat neck supple jvp at clavicle at degrees no lad cv irregularly irregular with no murmurs appreciated lungs clear to auscultation bilaterally no wheezes rales rhonchi abdomen soft non tender non distended bowel sounds present no organomegaly no rebound or guarding gu no foley ext warm well perfused pulses no clubbing cyanosis or edema discharge physical exam vitals afebrile 100s 110s 70s room air weight kg telemetry af afl ivcd general sitting upright and eating in nad neck mild r trapezius tension no carotid bruit jvp not elevated cv irregularly irregular with no murmurs appreciated lungs clear to auscultation bilaterally no wheezes rales rhonchi abdomen soft non tender non distended bowel sounds present no organomegaly no rebound or guarding gu no foley ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs 34am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 34am blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 34am blood ptt 46am blood ret aut abs ret 34am blood glucose urean creat na k cl hco3 angap 46am blood totbili 34am blood probnp 34am blood ctropnt 46am blood ck mb ctropnt 46am blood calcium phos mg 46am blood hapto 05pm blood osmolal 46am blood digoxin 08pm urine color yellow appear hazy sp 08pm urine blood neg nitrite neg protein neg glucose neg ketone neg bilirub neg urobiln neg ph leuks lg 08pm urine rbc wbc bacteri many yeast none epi 08pm urine casthy 14am urine hours random creat na 14am urine osmolal micro labs blood culture blood culture routine final negative blood culture blood culture routine final negative images cxr compared with the left heart border is less well defined but the cardiomediastinal silhouette is enlarged and not significantly changed there is patchy opacity at the left lung base which may account for indistinctness of the left heart border left hemidiaphragm remains visible there is minimal atelectasis at the right lung base no overt chf no gross effusion no pneumothorax detected renal us normal renal ultrasound specifically no hydronephrosis discharge labs 20am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 35am blood ptt 35am blood glucose urean creat na k cl hco3 angap 35am blood calcium phos mg brief hospital course ms is an year old woman with a pmh of cad afib sleep apnea who is presenting with chest pain her weight on admission was kg less than previously and she had a new thought to be due to overdiuresis her troponins were negative and ekg was reassuring no further ischemic work up was performed given her age and comorbidities her diuresis was held initially and restarted to torsemide mg with goal euvolemia her improved thought to be secondary to overdiuresis as an outpatient her bp medications were adjusted decreased metop xl increased hydral held losartan and spironolactone given given her apixaban was discontinued and she was bridged to warfarin with heparin gtt for her atrial fibrillation her digoxin was discontinued given her tenuous renal function she was treated for an uncomplicated uti w cefpodoxime culture was not sent chronic systolic and diastolic chf tte on with lvef mild biventricular dilation severe lv hypokinesis of the septum and inferior walls and mild hypokinesis of the remaining segments mr mild pulmonary htn bnp less than last admission as above during recent hospitalization was felt to be volume up and torsemide dose was increased then subsequently decreased due to she does not appear volume overloaded on exam cxr w questionable lll opacity discharge weight was kg that hospitalization and kg on admission she was transitioned to torsemide mg po for net even euvolemia her home losartan and spironolactone were held given her her home imdur was continued her hydralazine was increased from mg daily to mg tid her metoprolol was decreased from xl mg to mg daily acute kidney injury cr has increased since discharge of was on admission thought to be related to overdiuresis it was stable at upon discharge her home losartan digoxin apixaban and spironolactone were held urinary tract infection ua w leuk positive wbc many bacteria did not receive ucx s p ctx and transition to cefpo she completed a 7d course on resolved chest pain ekg and trop reassuring and patient appearing generally comfortable previously has had chest pain in the setting of heart failure exacerbations after previous admission was discharged on increased dose of torsemide from 40mg qam 20mg qpm to 40mg bid though this was subsequently reduced again given findings as outpatient trop 2x negative cxr with left sided opacity bnp around baseline discontinued doxycycline as low concern for pna on cxr deferring stress test given age and comorbidities continued on aspirin gm daily and atorvastatin mg daily thrombocytopenia unclear cause with no history of liver failure and no signs of infection or hemolysis unlikely to be from heparin or ctx as she was tcp on admission prior to receiving these medications coronary artery disease history of vessel cad left main proximal and lad proximal w diffuse dz confirmed on cath at had previous cath with small vessel disease last nuclear stress test with moderate fixed inferior wall defect continued aspirin and atorvastatin insulin dependent diabetes mellitus glargine 34u qam 10u qpm with insulin sliding scale atrial fibrillation switched eliquis to warfarin with heparin gtt bridge given her digoxin was discontinued hyperlipidemia continued atorvastatin 40mg qhs obstructive sleep apnea continued home cpap machine transitional issues discharge weight kg new medications warfarin mg and mg on alternating days changed medications hydralazine decreased from mg daily to mg tid metop xl decreased from mg daily to mg daily torsemide was changed from mg qam and mg qpm to mg daily held medications losartan daily spironolactone mg daily given ckd and apixiban mg bid digoxin mg qd given tenuous renal function anticoagulation will determine anticoagulation management with either or on in the interim the primary team at will determine coumadin dosing inr check discharge was she will need another irn draw on will check this and fax to in patient resident team clinic will be arranged on closed over the weekend labs her last hgb was platelets and creatinine was please recheck at her next outpatient appointment code full confirmed contact daughter hcp cell phone medications on admission the preadmission medication list is accurate and complete apixaban mg po bid aspirin mg po daily atorvastatin mg po qpm cyanocobalamin mcg po daily docusate sodium mg po bid metoprolol succinate xl mg po bid senna mg po bid torsemide mg po qam vitamin d unit po daily isosorbide mononitrate extended release mg po daily spironolactone mg po daily oxycodone acetaminophen mg oral tid torsemide mg po qpm hydralazine mg po daily losartan potassium mg po bid digoxin mg po daily gabapentin mg po tid pantoprazole mg po q24h levemir flextouch insulin detemir unit ml ml subcutaneous units qam units qpm humalog kwikpen insulin lispro unit ml subcutaneous per sliding scale discharge medications warfarin mg po daily16 rx warfarin mg tablet s by mouth daily disp tablet refills hydralazine mg po q8h rx hydralazine mg tablet s by mouth three times a day disp tablet refills metoprolol succinate xl mg po daily rx metoprolol succinate mg tablet s by mouth daily disp tablet refills aspirin mg po daily atorvastatin mg po qpm cyanocobalamin mcg po daily docusate sodium mg po bid gabapentin mg po tid humalog kwikpen insulin lispro unit ml subcutaneous per sliding scale isosorbide mononitrate extended release mg po daily levemir flextouch insulin detemir unit ml ml subcutaneous units qam units qpm oxycodone acetaminophen mg oral tid pantoprazole mg po q24h senna mg po bid torsemide mg po qam vitamin d unit po daily discharge disposition home with service facility discharge diagnosis primary diagnosis acute on chronic kidney injury heart failure with systolic dysfunction hypertension atrial fibrillation secondary diagnosis obstructive sleep apnea hyperlipidemia coronary artery disease discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions ms you were admitted for kidney injury and chest pain your chest pain resolved on it s own and you had no heart damage because of your kidney impairment you required a blood thinner through the iv and you were started on an oral blood thinner called coumadin warfarin please stop taking your eliquis as the warfarin will replace that you will need frequent blood draws to monitor the inr which is a level of how thin your blood is your blood pressure medication was adjusted see below and you will take torsemide mg daily to start weigh yourself as soon as you get home and every morning call md if weight goes up or down by more than lbs please follow up with your cardiologist as an outpatient it was a pleasure caring for you medical care team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies morphine indocin nafcillin attending chief complaint dyspnea major surgical or invasive procedure none history of present illness patient is a year old aa woman with a pmh significant for htn hld t2dm hfref lvef stage ckd afib on warfarin osa on cpap who presented to the ed with sob lower extremity edema and chest pain pt reports worsening since of usual upper lower back pain and chest pain she came to pain clinic on day of admission for her chronic back pain where they referred her to ed for her dyspnea dyspnea has been worsening over the last week worse with exertion over the last weeks has been eating salty foods fried chicken fast food because her refrigerator broke usually adheres to a healthy diet with home cooked meals with very little added salt cp is her usual angina by location and character stabbing left of sternum occurs both at rest and on exertion does not radiate nitro gives complete relief last taken x2 at 6am on she has had this same chest pain times per week over many years notably she has uti with urine cultures positive for e coli currently on cefpodoxime mg bid prescribed by her gynecologist which she began she is incontinent at baseline denies dysuria increased frequency increased urinary urgency fevers chills nausea vomiting diarrhea past medical history infarct related systolic chf ef type iddm htn cad cath at in showing small vessel disease cardiac cath in showing single vessel disease no intervention atrial fibrillation ckd stage osa on cpap gout non hodgkin s lymphoma multinodular goiter glaucoma chronic low back pain s p lumbar decompression surgery osteoporosis urinary incontinence s p tah and bso s p bilateral knee replacements s p bilateral eye surgery social history family history diabetes grandmother died of mi at father mi in mother died before her of heart condition that was undiagnosed physical exam admission physical exam general short of breath at rest difficulty carrying conversation appears tired pleasant heent ncat sclera anicteric perrl eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthelasma neck supple with distended neck veins no jvp cardiac irregularly irregular no rubs murmurs or gallops lungs clear to auscultation bilaterally no wheezes or crackles abdomen soft ntnd no hsm or tenderness bowel sounds present extremities pitting edema to shins bilaterally no cyanosis or clubbing skin no rashes bilateral linear knee scars from knee replacement surgery pulses distal pulses palpable and symmetric discharge physical exam vitals t po bp lying hr rr weight admission kg lb today kg standing is os 24h cc cc since midnight cc general obese resting in bed comfortably with nebs no acute distress neck supple jvp unassessable given afib cardiac irregularly irregular s4 and i vi systolic murmur loudest at apex no rubs lungs clear to auscultation bilaterally no wheezes rhonchi or rales abdomen soft ntnd obese gu no foley in place no suprapubic tenderness extremities no edema cyanosis clubbing skin no rashes bilateral linear knee scars from knee replacement surgery pulses distal pulses palpable and symmetric pertinent results admission labs 40am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 40am blood neuts monos eos baso nrbc im absneut abslymp absmono abseos absbaso 40am blood ptt 40am blood glucose urean creat na k cl hco3 angap 40am blood ck mb ctropnt probnp 40am blood calcium phos mg 49am blood lactate discharge labs 30am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30am blood 10am blood glucose urean creat na k cl hco3 angap 10am blood calcium phos mg diagnostic studies cxr findings the heart is enlarged stable the trachea is midline there is mild pulmonary edema unchanged when allowing for differences in technique mild degenerative changes are seen in the spine impression mild pulmonary edema cardiomegaly cxr findings cardiac silhouette size remains mildly enlarged mediastinal and hilar contours are unremarkable lung volumes remain low mild pulmonary edema appears new in the interval no focal consolidation pleural effusion or pneumothorax is seen there are mild degenerative changes seen in the thoracic spine mild pulmonary edema new in the interval brief hospital course ms is an year old woman with a pmh of hfref htn hld type dm stage ckd afib on warfarin osa on cpap who presented with sob lower extremity edema and chest tightness found to have acute on chronic heart failure exacerbation secondary to high salt diet at home over last weeks problems addressed during this hospitalization are listed below active issues acute on chronic heart failure with reduced ejection fraction ef patient presented with elevated bnp worsening shortness of breath volume overloaded on physical exam and cxr etiology most likely diet related as patient reported eating high salt diet over the last weeks fridge at home broke patient compliant with home medications lives with her son who monitors medications no significant concern for missed mi as trop negative on admission was diuresed with iv lasix as needed then transitioned to torsemide mg po bid previously discharged in on torsemide daily her hydralazine was also decreased to in order to make room to increase her isosorbide mononitrate xr to mg qd to alleviate her non exertional chest pain below she also had her metoprolol succinate xl increased from mg daily to mg daily coronary artery disease non exertional chest pain is chronic issue that occurs times per week over many years presented with chest tightness trops elevated on admission but mb flat likely related to ckd cath at in showed small vessel disease repeat cardiac cath in showed single vessel disease without any intervention had one episode of cp this admission relieved with sl nitros no ekg changes trops continue aspirin mg atorvastatin mg sl nitro as needed and isosorbide mononitrate mg increased from prior discharge as described above uti urge incontinence patient has a history of urge incontinence for approx year made appt to see obgyn in planned urodynamic study on but was aborted given a urinalysis showed nitrates and over wbcs patient incontinent at home and mostly using adult diapers tried intermittent cath briefly asymptomatic throughout admission foley was placed to monitor ins and outs urine was notably hazy urine culture from grew pansensitive e coli completed course of cefpodoxime mg bid prescribed by outpatient gynecologist will need follow up with obgyn again sent home with another course of cefpodoxime mg bid given a positive ua admission cr values ranged from throughout hospital course baseline cr most likely etiology reduced renal perfusion and increased venous pressure from chf exacerbation chronic stable issues chronic low back pain present throughout admission remained at baseline continued home gabapentin mg po tid home lidocaine patch prn given oxycodone mg po q4h prn held home oxycodone acetaminophen mg oral tid type iddm morning sugars 60s before breakfast patient confirms that this happens at home too optimized with glargine units at bedtime and iss will need follow up with endocrinologist as outpatient htn continued metoprolol hydralazine and isosorbide mononitrate changes to dosing as above permanent atrial fib w rvr continued metoprolol as above and home warfarin decreased to mg qd due to supratherapeutic inrs on admission peak inr osa on cpap continued cpap at night normocytic anemia remained stable gout held home allopurinol bid minutes spent on discharge planning coordination of care transitional issues please see changes and additions to medications patient requires follow up with the heart failure nurse practitioner at the cardiac direct access unit on please check basic metabolic panel potassium creatinine within week as home torsemide dose increased from to mg bid on discharge please check inr and ensure patient compliant and therapeutic with new warfarin dose of mg daily patient was started on cefpodoxime for a urinary tract infection last patient need to have a urodynamic study performed this was previously deferred given a uti please re check urinalysis for evidence of uti prior to obgyn appt on her hydralazine was decreased to 10mg tid to increase the imdur to 60mg daily for better anti anginal therapy patient requires follow up with with her endocrinologist dr within weeks of discharge to adjust home insulin regimen consider switching from warfarin to rivaroxaban apixaban renal dosing given very low ttr on warfarin code status full code confirmed contact daughter medications on admission the preadmission medication list is accurate and complete aspirin mg po daily atorvastatin mg po qpm cyanocobalamin mcg po daily docusate sodium mg po bid gabapentin mg po tid hydralazine mg po q8h isosorbide mononitrate extended release mg po daily metoprolol succinate xl mg po daily oxycodone acetaminophen mg oral tid pantoprazole mg po q24h senna mg po bid vitamin d unit po daily humalog kwikpen insulin lispro unit ml subcutaneous per sliding scale levemir flextouch insulin detemir unit ml ml subcutaneous units in the morning units in the evening torsemide mg po qam warfarin mg po daily16 allopurinol mg po bid nitroglycerin sl mg sl q5min prn chest pain discharge medications cefpodoxime proxetil mg po q12h duration days rx cefpodoxime mg tablet s by mouth twice a day disp tablet refills rx cefpodoxime mg tablet s by mouth twice a day disp tablet refills hydralazine mg po q8h rx hydralazine mg one tablet s by mouth every eight hours disp tablet refills isosorbide mononitrate extended release mg po daily rx isosorbide mononitrate mg one tablet s by mouth once a day disp tablet refills metoprolol succinate xl mg po daily rx metoprolol succinate mg tablet s by mouth daily disp tablet refills torsemide mg po bid rx torsemide mg tablet s by mouth twice a day disp tablet refills allopurinol mg po bid aspirin mg po daily atorvastatin mg po qpm cyanocobalamin mcg po daily docusate sodium mg po bid gabapentin mg po tid humalog kwikpen insulin lispro unit ml subcutaneous per sliding scale levemir flextouch insulin detemir unit ml ml subcutaneous units in the morning units in the evening nitroglycerin sl mg sl q5min prn chest pain oxycodone acetaminophen mg oral tid pantoprazole mg po q24h senna mg po bid vitamin d unit po daily warfarin mg po daily16 hospital bed hospital bed length years diagnosis chronic diastolic congestive heart failure i50 limited mobility severe shortness of breath on exertion oxygen oxygen therapy length years portable o2 tank and concentrator unit diagnosis i50 chronic diastolic congestive heart failure severe shortness of breath on exertion and desaturation to outpatient lab work icd9 please check chem inr on please fax results to md discharge disposition home with service facility discharge diagnosis primary diagnosis acute on chronic heart failure with reduced ejection fraction acute on chronic kidney injury secondary diagnosis coronary artery disease hypertension hyperlipidemia type diabetes mellitus stage chronic kidney disease atrial fibrillation obstructive sleep apnea urinary tract infection gout chronic back pain discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid discharge instructions dear ms it was a pleasure to care for you at the why was i admitted to the hospital you came to the hospital because you were having shortness of breath and swelling in your legs you were found to have extra fluid in your body we believe this happened because you ate a high salt diet for several weeks before coming to the hospital and this worsened your heart failure what happened while i was admitted we treated you with medication to remove this extra fluid from your body your shortness of breath and swelling improved with this medication you developed some chest pain in the hospital which was similar to the chest pain you often experience at home we monitored this with blood tests and ekgs which evaluate the electrical activity of the heart we also continued to treat you with antibiotics for a urinary tract infection that you had before you came to the hospital what should i do when i go home please follow up with your primary care doctor and our heart failure clinic as listed below please maintain a low salt diet salt causes your body to retain fluid which makes you short of breath please continue to take your antibiotic cefpodoxime for the urinary tract infection for the next days last please weigh yourself in the morning everyday call your primary care doctor or the heart failure clinic if your weight increases by more than lbs over days we wish you all the your cardiology team followup instructions

name unit no admission date discharge date date of birth sex m service surgery allergies sulfa sulfonamide antibiotics attending chief complaint facial pain major surgical or invasive procedure none history of present illness y o m transferred for trauma evaluation after a fall patient poorly fell down a flight of stairs had imaging which showed a facial fractures as well as a small cerebral contusion here patient complains of pain to his head and neck denies other injuries past medical history pmhx cad angina mi gerd hcv hl migraines osa atrophic l kidney pshx appendectomy carpal tunnel release spine surgery cervical social history family history non contributory physical exam admission physical exam temp hr bp resp o sat normal constitutional constitutional lying in bed protecting airway head eyes nc perrl eomi left periorbital ecchymosis ent op wnl resp ctab cards rrr abd s nt nd pelvis stable skin no rash warm and dry ext no c c e neuro speech fluent psych normal mood discharge physical exam gen awake alert pleasant and interactive cv rrr pulm clear to auscultation bilaterally abd soft non tender non distended active bowel sounds ext warm and dry pulses pertinent results 22am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 22am blood glucose urean creat na k cl hco3 angap 30am blood alt ast alkphos totbili 22am blood calcium phos mg 43am blood lactate brief hospital course mr is a yo m who presented to emergency department after reportedly a fall down a flight of stairs sustaining left sided facial trauma he was hemodynamically stable ct head negative for acute intracranial process imaging reveals a small left zygomatic arch fracture left orbital floor fracture and lateral orbital wall fracture the patient was seen and evaluated by plastic surgery who recommended non operative management of his fractures the patient was evaluated for ophthalmology for eye injury muscle entrapment which there was none he was admitted to the surgical floor for observation and pain control pain medication were titrated with good effect on hd4 he was discharged to home on sinus precautions doing well afebrile and hemodynamically stable the patient was tolerating a diet ambulating voiding without assistance and pain was well controlled the patient received discharge teaching and follow up instructions with understanding verbalized and agreement with the discharge plan medications on admission the preadmission medication list is accurate and complete nifedipine extended release mg po daily simvastatin mg po qpm terazosin mg po qhs fluoxetine mg po daily sumatriptan succinate mg sc once prn headache nitroglycerin sl mg sl q5min prn chest pain omeprazole mg po daily hydromorphone dilaudid mg po tid pain diazepam mg po qhs anxiety gabapentin mg po tid morphine sr ms mg po q12h discharge medications acetaminophen mg po q8h prn pain mild do not exceed mg tylenol hours docusate sodium mg po bid ibuprofen mg po q8h prn pain mild reason for prn duplicate override alternating agents for similar severity alternate with tylenol omeprazole mg po daily polyethylene glycol g po daily prn constipation senna mg po bid prn constipation hydromorphone dilaudid mg po q8h prn pain severe hydromorphone dilaudid mg po q4h prn breakthrough pain rx hydromorphone dilaudid mg tablet s by mouth every four hours disp tablet refills diazepam mg po qhs anxiety fluoxetine mg po daily gabapentin mg po tid morphine sr ms mg po q12h nitroglycerin sl mg sl q5min prn chest pain simvastatin mg po qpm sumatriptan succinate mg sc once prn headache terazosin mg po qhs held nifedipine extended release mg po daily this medication was held do not restart nifedipine extended release until instructed by primary care provider discharge disposition home discharge diagnosis left comminuted maxillary sinus fracture both walls small left zygomatic arch fracture small left orbital floor fracture small lateral orbital wall fracture 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 acute care trauma surgery service on after a fall sustaining multiple facial injuries you were seen by the plastic surgery team who evaluated your facial fractures and recommended non operative management at this time and follow up in outpatient clinic to determine if further surgery is needed please continue to follow sinus precautions no nose blowing sneeze with your mouth open no drinking through straws you were evaluated by the ophthalmology team who determined there are no injuries to your eyes that require intervention at this time please follow up in clinic to re evaluate your vision and assess for worsening symptoms you are now doing better tolerating a regular diet and ready to be discharge to home to continue your recovery please note the following discharge instructions please call your doctor or nurse practitioner or return to the emergency department for any of the following you experience new chest pain pressure squeezing or tightness new or worsening cough shortness of breath or wheeze if you are vomiting and cannot keep down fluids or your medications you are getting dehydrated due to continued vomiting diarrhea or other reasons signs of dehydration include dry mouth rapid heartbeat or feeling dizzy or faint when standing you see blood or dark black material when you vomit or have a bowel movement you experience burning when you urinate have blood in your urine or experience a discharge your pain in not improving within hours or is not gone within 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 neurosurgery allergies no known allergies adverse drug reactions attending chief complaint left temporal cavernous malformation major surgical or invasive procedure left craniotomy for resection of left temporal cavernous malformation history of present illness is a year old male with a known left temporal cavernous malformation who presented electively on for a left craniotomy for resection past medical history cervical spondylosis depression left temporal cavernous malformation status post hernia repair status post right hip surgery social history family history noncontributory physical exam on discharge general vital signs t 8f hr bp o2sat on room air exam opens eyes x spontaneous to voice to noxious none orientation x person x place x time follows commands simple x complex none pupils pupils equally round and reactive to light bilaterally extraocular movements x full restricted face symmetric x yes no tongue midline x yes no drift yes x no speech fluent x yes no comprehension intact x yes no motor trapezius deltoid biceps triceps grip right left ip quadriceps hamstring at gastrocnemius right left sensation intact to light touch left craniotomy incision x clean dry intact x sutures pertinent results please see for relevant laboratory and imaging results brief hospital course year old male with a known left temporal cavernous malformation left temporal cavernous malformation the patient presented electively on and was taken to the or for a left craniotomy for resection of the left temporal cavernous malformation the operation was uncomplicated please see omr for further intraoperative details the patient was extubated in the or and recovered in the pacu postoperatively he was then transferred to the step down unit for close neurologic monitoring he was started on keppra postoperatively for seizure prophylaxis he was also put on a dexamethasone taper to help with his headaches the patient remained neurologically stable postoperatively on he was afebrile with stable vital signs mobilizing independently tolerating a diet voiding and stooling without difficulty and his pain was well controlled with oral pain medications he was discharged home with no needs on in stable condition he will follow up for suture removal days after surgery and with dr weeks after surgery disposition the patient was mobilizing independently postoperatively he was discharged home with no needs on in stable condition medications on admission cholecalciferol escitalopram oxalate 10mg po once daily fish oil riboflavin discharge medications acetaminophen mg po q6h prn pain mild do not exceed 3000mg in hours wean off as tolerated dexamethasone mg po q8h duration dose step this is dose of tapered doses rx dexamethasone mg tablet s by mouth every eight hours disp tablet refills dexamethasone mg po q8h duration doses step this is dose of tapered doses tapered dose down rx dexamethasone mg tablet s by mouth every eight hours disp tablet refills dexamethasone mg po q8h duration doses step this is dose of tapered doses tapered dose down rx dexamethasone mg tablet s by mouth every eight hours disp tablet refills dexamethasone mg po q12h duration doses step this is dose of tapered doses tapered dose down rx dexamethasone mg tablet s by mouth every twelve hours disp tablet refills docusate sodium mg po bid prn constipation first line do not take if having loose stools stop taking once off oxycodone famotidine mg po bid stop taking once off dexamethasone rx famotidine mg tablet s by mouth twice a day disp tablet refills levetiracetam mg po bid rx levetiracetam mg tablet s by mouth twice a day disp tablet refills oxycodone immediate release mg po q4h prn pain moderate wean off as tolerated rx oxycodone mg tablet s by mouth every four hours as needed for pain disp tablet refills senna mg po qhs prn constipation second line do not take if having loose stools stop taking once off oxycodone escitalopram oxalate mg po daily discharge disposition home discharge diagnosis left temporal cavernous malformation discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions care of the surgical incision keep your surgical incision clean and dry do not rub scrub scratch or pick at any scabs along the surgical incision you may use water to wash your hair around your surgical incision but do not use shampoo until your sutures are removed you will need to have your sutures removed days after surgery when you are allowed to use shampoo let the shampoo run off the surgical incision and gently pad the surgical incision with a towel to dry activity start to resume all activities as tolerated but start slowly and increase at your own pace do not operate any motorized vehicle for at least days after your surgery do not operate any motorized vehicle while taking narcotics medications please do not take any blood thinning medications such as aspirin clopidogrel plavix warfarin coumadin etc until cleared by your neurosurgeon please do not take any anti inflammatory medications such as advil aleve ibuprofen motrin etc until cleared by your neurosurgeon please call your neurosurgeon if you experience redness swelling or drainage from your surgical incision fever greater than degrees fahrenheit headaches not relieved with prescribed medications any neurologic issues such as changes in vision speech or movement any problems with medications such as lethargy nausea or vomiting postoperative experiences physical fatigue is common this will slowly resolve over time numbness or tingling at the surgical incision is common this can take weeks or months to fully resolve muffled hearing in the ear on the same side as your surgical incision is common jaw pain on the same side as your surgical incision is common this goes away after about month low back pain or shooting pain down the leg is possible this should resolve with increased activity you may experience constipation constipation can be prevented by drinking plenty of fluids increasing the fiber in your diet and exercising you may also use an over the counter stool softener if needed postoperative experiences emotional you may experience depression symptoms of depression can include feeling sad or down loneliness confusion irritability frustration distractibility low self esteem relationship challenges and insomnia if you experience any of these symptoms please contact your primary care provider for referral to a psychologist or psychiatrist followup instructions

name unit no admission date discharge date date of birth sex m service surgery allergies lisinopril banana attending chief complaint rectal pain major surgical or invasive procedure exam under anesthesia and incision and drainage of posterior perirectal abscess history of present illness hx cad mi x2 dm presenting with rectal pain described as burning in nature exacerbated by sitting and with defection and notes subjective fever last night wbc ctap with 2cm rim enhancing collection in posterior midline at level of sphincters no personal or family history of inflammatory bowel disease or colorectal cancer no prior episodes no change in bowel habits at time of consultation pt afvss with dre notable for fluctuance and tenderness in the posterior midline no blood or drainage past medical history pmh dm2 htn glaucoma hl cad mix2 psh prostate needle biopsy social history family history no family history of ibd crc father cad pvd physical exam admission physical exam weight vs t hr bp rr sao2 rm air gen nad a ox3 heent eomi mmm cv tachycardic pulm ctab back no cvat abd soft nt nd pelvis perianal exam unremarkable dre posterior midline fluctuance and tenderness at level of sphincters no blood no drainage ext warm well perfused discharge physical exam pertinent results 20am glucose urea n creat sodium potassium chloride total co2 anion gap 20am wbc rbc hgb hct mcv mch mchc rdw rdwsd 20am plt count 17am glucose urea n creat sodium potassium chloride total co2 anion gap 17am wbc rbc hgb hct mcv mch mchc rdw rdwsd 17am plt count 05pm lactate 55pm glucose urea n creat sodium potassium chloride total co2 anion gap 55pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 55pm neuts monos eos basos im absneut abslymp absmono abseos absbaso 55pm plt count 40pm urine color yellow appear clear sp 40pm urine blood neg nitrite neg protein tr glucose neg ketone bilirubin neg urobilngn ph leuk neg 40pm urine rbc wbc bacteria none yeast none epi 40pm urine mucous rare imaging ct pelvis cm rim enhancing midline fluid collection just posterior concerning forpossible perirectal abscess sigmoid colon diverticulosis without evidence of diverticulitis enlarged prostate brief hospital course mr is a year old male who presented to with complaints of rectal pain and received a ct pelvis which showed him to have a perirectal abscess he was admitted to the acute care surgery team for further medical evaluation on the patient was taken to the operating room and underwent incision and drainage of his perirectal abscess he tolerated this procedure well reader please see operative note for further information post operatively the patient received iv antibiotics on post op day patient noticed to have some pain and induration just anterior to the incision mri showed small residual abscess we took him back to the or and another i d please refer to the operative note for more information he tolerated this procedure well and transferred to the regular floor the remainder of the hospital course is summarized by systems below neuro the patient was alert and oriented throughout hospitalization pain was managed with 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 s diet was advanced sequentially to a regular diet which was well tolerated patient s intake and output were closely monitored id the patient s fever curves were closely watched for signs of infection and he received antibiotics post operatively heme the patient s blood counts were closely watched for signs of bleeding of which there were none prophylaxis the patient received subcutaneous heparin and dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible at the time of discharge the patient was doing well afebrile and hemodynamically stable the patient was tolerating a diet ambulating voiding without assistance and pain was well controlled the patient received discharge teaching and follow up instructions with understanding verbalized and agreement with the discharge plan medications on admission polyethylene glycol prn gatifloxacin prednisolone q2h metformin hctz losartan toprol xl atorvastatin alphagan cosopt l eye latanprost discharge medications acetaminophen mg po tid aspirin mg po daily atorvastatin mg po qpm dorzolamide timolol ophth drop left eye bid lorazepam mg po q4h prn anxiety metformin xr glucophage xr mg po daily metoprolol succinate xl mg po daily omeprazole mg po daily senna mg po bid prn constipation hydrochlorothiazide mg po daily losartan potassium mg po daily prednisolone acetate ophth susp drop both eyes bid latanoprost ophth soln drop both eyes qhs gatifloxacin ophthalmic qid docusate sodium mg po bid oxycodone immediate release mg po q3h prn pain rx oxycodone mg tablet s by mouth q3 disp tablet refills ciprofloxacin hcl mg po q12h rx ciprofloxacin hcl mg tablet s by mouth q12 disp tablet refills metronidazole flagyl mg po q8h rx metronidazole mg tablet s by mouth q8 disp tablet refills discharge disposition home with service facility discharge diagnosis perirectal abscess discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr you presented to the and were found to have an abscess you were admitted to the acute care surgery team for further medical management on you were taken to the operating room and underwent an incision and drainage of your abscess which you tolerated well you were started on antibiotics to treat and prevent infection your pain is better controlled and you are tolerating a regular diet you are now medically cleared to be discharged to home please note the following discharge instructions please call your doctor or nurse practitioner or return to the emergency department for any of the following you experience new chest pain pressure squeezing or tightness new or worsening cough shortness of breath or wheeze if you are vomiting and cannot keep down fluids or your medications you are getting dehydrated due to continued vomiting diarrhea or other reasons signs of dehydration include dry mouth rapid heartbeat or feeling dizzy or faint when standing you see blood or dark black material when you vomit or have a bowel movement you experience burning when you urinate have blood in your urine or experience a discharge your pain in not improving within hours or is not gone within 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 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 followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies lamotrigine levetiracetam attending chief complaint found down major surgical or invasive procedure left hd line insertion right ij line insertion hd line placement removed intubation s p extubation history of present illness with unknown medical history but is resident of a group home was found down by her pt presented initially to osh ed where she was evaluated with ct head which was negative cta showed bilateral saddle pulmonary embolisms and whe was started on heparin gtt w 6000u bolus and 1800cc hr she was transferred to for further evaluation an arrival to the patient continued to be hypoxemic and became altered and was intubated for airway protection during intubation the patient was noted to be progressively more hypotensive a radial a line was placed she was evaluated with a stat ct head which showed no acute intracranial pathology the patient s hemodynamics improved the ed initial vitals were hr bp rr o2 on nrb labs wbc hgb hct plt cr hco3 phos alt ast ap alb troponin bnp ua sg protein few bacteria inr abg ph pco2 po2 hco3 lactate imaging cxr tip of the et tube situated cm above the carina at the thoracic inlet dilatation of the main and left pulmonary artery compatible with known pulmonary embolism ct head somewhat motion degraded study this limitation no acute intracranial process bedside tte showed r heart strain consults cardiology patient was given fentanyl decision was made to admit to ccu for management of pe review of systems per hpi all other ros otherwise negative past medical history ptsd t2dm gerd hyperlipidemia sleep walking and night terrors copd subclinical hypothyroidism mood disorder with psychosis anorexia nervosa tobacco use renal insufficiency history of empyema borderline personality disease lower extremity edema diabetic foot ulcer social history family history no family history of heart disease clotting disorder or malignancy physical exam admission exam vs t97 hr bp rr o2 weight 5kg gen intubated sedated heent purple discoloration to upper chest neck jvd appears elevated but difficult to appreciate cv tachycardic nl s1 s2 on m r g lungs cta anteriorly over ventilator abd soft nt nd nabs ext wwp no edema neuro opens eyes to name exam vs 99ra i o poorly recorded 3bms weights not recorded gen nad laying bed heent no elevated jvd dysphonic mmm cv rrr no m r g resp ctab abd soft nt nd bs ext no edema wwp neuro follows commands appropriately strength ue and a ox3 pertinent results microbiology c difficile dna amplification assay final reported to and read back by 25am clostridium difficile positive for toxigenic c difficile by the illumigene dna amplification mrsa screen final no mrsa isolated urine culture final escherichia coli organisms ml presumptive identification cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h sensitivities mic expressed mcg ml escherichia coli ampicillin s ampicillin sulbactam s cefazolin s cefepime s ceftazidime s ceftriaxone s ciprofloxacin s gentamicin s meropenem s nitrofurantoin s piperacillin tazo s tobramycin s trimethoprim sulfa s gram stain final pmns and epithelial cells 100x field per 1000x field gram positive cocci pairs and clusters respiratory culture final moderate growth commensal respiratory flora yeast rare growth this organism considered to be part of the commensal respiratory flora blood culture routine final viridans streptococci isolated from only one set the previous five days workup requested by final sensitivities ceftriaxone requested sensitivities mic expressed mcg ml viridans streptococci ceftriaxone s clindamycin s erythromycin r penicillin g s vancomycin s anaerobic bottle gram stain final gram positive cocci pairs and chains imaging reports tte the left atrium and right atrium are normal cavity size left ventricular wall thickness cavity size and regional global systolic function are normal lvef tissue doppler imaging suggests a normal left ventricular filling pressure pcwp 12mmhg the right ventricular cavity is mildly dilated with severe global free wall hypokinesis 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 mild pulmonary artery systolic hypertension there is no pericardial effusion impression dilated right ventricle with severe rv systolic dysfunction normal left ventricular systolic function mild pulmonary hypertension the setting of severe rv dysfunction ct head findings the study is somewhat motion degraded given this limitation there is no evidence of infarction hemorrhage edema or mass the ventricles and sulci are normal size and configuration there is no evidence of fracture the visualized portion of the paranasal sinuses mastoid air cells and middle ear cavities are clear the visualized portion of the orbits are unremarkable impression somewhat motion degraded study this limitation no acute intracranial process abdominal u s findings liver the hepatic parenchyma appears within normal limits the contour of the liver is smooth there is a focal echogenic mass the left lobe measuring x x cm with geographic borders the main portal vein is patent with hepatopetal flow there is no ascites the hepatic veins are patent bile ducts there is no intrahepatic biliary dilation the cbd measures mm gallbladder the gallbladder contains sludge but is non dilated and there is no pericholecystic fluid pancreas imaged portion of the pancreas appears within normal limits without masses or pancreatic ductal dilation with portions of the pancreatic tail obscured by overlying bowel gas spleen normal echogenicity measuring cm kidneys the right kidney measures cm the left kidney measures cm normal cortical echogenicity and corticomedullary differentiation is seen bilaterally there is no evidence of masses stones or hydronephrosis the kidneys limited evaluation of renal vascularity demonstrates patent renal arteries veins with normal waveforms retroperitoneum visualized portions of aorta and ivc are within normal limits impression patent hepatic veins and main portal vein patent bilateral renal vasculature evaluation of the renal vasculature is slightly limited due to patient s body habitus incidental geographic hyperechoic lesion the left lobe of liver likely hemangioma or focal fatty infiltration the absence of a history of known neoplasm sludge within the gallbladder without evidence of cholecystitis ct head impression when compared to prior examination of there is apparent increased sulcal effacement of the bilateral cerebral convexities which may be representative of edema from prolonged hypoxia and ischemia the finding may be artifactual secondary to technique however mri could be performed for confirmation there is no diffuse loss of gray white differentiation nor is there evidence of acute large territorial infarct no intracranial hemorrhage mri brain findings there is no evidence of hemorrhage edema masses mass effect midline shift or infarction the ventricles and sulci are normal caliber and configuration there is mucosal thickening the visualized paranasal sinuses the orbits are unremarkable there is fluid opacification of bilateral mastoid air cells with secretions the nasopharynx likely secondary to intubation impression no acute intracranial abnormality paranasal sinus inflammatory disease tte normal left ventricular wall thickness cavity size and global systolic function 3d lvef the right ventricular cavity is mildly dilated with mild global free wall hypokinesis tricuspid annular plane systolic excursion is normal cm mildly abnormal setting of mild rv dilation there is abnormal systolic septal motion position consistent with right ventricular pressure overload the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation no masses or vegetations are seen on the aortic valve but cannot be fully excluded due to suboptimal image quality the mitral valve leaflets are mildly thickened there is no mitral valve prolapse no masses or vegetations are seen on the mitral valve but cannot be fully excluded due to suboptimal image quality trivial mitral regurgitation is seen no masses or vegetations are seen on the tricuspid valve but cannot be fully excluded due to suboptimal image quality there is moderate pulmonary artery systolic hypertension there is no pericardial effusion impression no echocardiographic evidence of cardiac emboli noted mild rv dilation and systolic function worse toward the apex with distal d shaped septum reverse sign compared with the prior study images reviewed of rv appears less dilated and systolic function more vigorous ekg clinical indication for ekg r06 shortness of breath sinus rhythm anteroseptal and lateral t wave changes may be due to ischemia compared to the previous tracing of right bundle branch block has resolved clinical indication for ekg qt interval for medication monitoring sinus bradycardia q t interval prolongation biphasic t waves leads ii iii and avf deep t wave inversion leads v1 v5 similar to that recorded on rule out myocardial infarction followup and clinical correlation are suggested video oropharyngeal swallow study barium passes freely through the oropharynx and esophagus without evidence of obstruction there was gross aspiration of nectar thick and thin liquids impression gross aspiration of nectar thick and thin liquids admission laboratory studies 13am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 13am blood neuts monos eos baso nrbc im absneut abslymp absmono abseos absbaso 13am blood ptt 00am blood fibrino 13am blood glucose urean creat na k cl hco3 angap 13am blood alt ast alkphos totbili 13am blood 13am blood albumin calcium phos mg 20am blood lactate 41am blood o2 sat 13am urine color yellow appear clear sp 13am urine blood neg nitrite neg protein glucose neg ketone neg bilirub neg urobiln ph leuks neg 13am urine rbc wbc bacteri few yeast none epi 13am urine mucous few coagulation studies 30am blood 55pm blood 35am blood ptt 10am blood ptt 10am blood ptt 00am blood ptt liver function tests 10am blood alt ast ld alkphos totbili 54am blood alt ast ld alkphos totbili 25am blood alt ast ld alkphos totbili 03am blood alt ast alkphos totbili 45am blood alt ast ld alkphos totbili 21am blood alt ast ld alkphos totbili 30am blood alt ast ld ck cpk alkphos totbili 35pm blood alt ck cpk alkphos totbili 00am blood alt ast ck cpk alkphos totbili 13am blood alt ast alkphos totbili other petinent laboratory studies 13am blood ctropnt 00am blood ck mb mb indx ctropnt 35pm blood ck mb mb indx ctropnt 30am blood ck mb ctropnt 30pm blood caltibc ferritn trf 30am blood tsh 30pm blood hbsag negative hbsab positive hbcab negative hav ab positive 34pm blood smooth negative 30pm blood ama negative 30pm blood igg iga igm 30pm blood asa neg ethanol neg acetmnp neg bnzodzp pos barbitr neg tricycl neg 30pm blood hcv ab negative discharge laboratory studies 30am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30am blood 30am blood glucose urean creat na k cl hco3 angap 10am blood alt ast ld ldh alkphos totbili 30am blood calcium phos mg with pmh ptsd t2dm hld copd tobacco use borderline personality disorder who presented after being found down by found to have massive pulmonary embolism s p tpa now on coumadin with course c b oliguric renal failure atn initially on hd now resolved off hd shock liver resolved strep viridans bacteremia cdif on po vanc last day saddle pulmonary embolism pt initially was found down by her and brought to an outside hospital where a cta showed bilateral saddle pulmonary embolisms for which she was started on heparin drip and transferred to on arrival to she was hypotensive and hypoxic and she was emergently intubated bnp troponin leak to and tte showing dilated right ventricle with severe rv systolic dysfunction were highly concerning for massive pe she became hypotensive requiring epinephrine and phenylephrine given her hemodynamic instability she was transitioned to full dose tpa she was transitioned to coumadin with a heparin drip bridge follow up tte showed improvement right heart strain she was discharged on coumadin with a goal inr of to given that this is apparently an unprovoked pe she will likely require lifelong anticoagulation acute hypoxic respiratory failure patient required intubation as stated above secondary to massive pe she was admitted to the ccu for the majority of her hospital course she was extubated on and did not require o2 by the time of discharge delirium complex psychiatric history pt has a complex psychiatric history of reported anorexia nervosa restrictive type borderline personality disorder and bipolar affective disorder during hospitalization pt developed waxing and waning sensorium and agitation psychiatry and neurology were consulted mri and ct of the head were negative her altered mental status was felt to be secondary to delirum due to her medical illness given level of sedation and multifactorial delirium her home ziprasidone prazosin gabapentin and clonazepam were initially held pt required precedex with a slow wean given agitation pt was managed on tid perphenazine and clonidine clonidine was eventually weaned off and she was restarted on her home prazosin to prevent withdrawal her home topiramate was weaned after weaning she was more alert and oriented and endorsed suicidal ideations and tried to tie a cord around her neck while pressing the call button for the nurse simultaneously given risk to harm herself she was placed on sitter pt later denied any thoughts of self harm or symptoms of depression per psychiatry she was not felt to meet criteria for involuntary psychiatric hospitalization and patient declined offer of voluntary admission pt was discharged with follow up scheduled with outpatient psychiatrist on pt was discharged on her home doses of clonazepam gabapentin perphenazine and prazosin she was started on lower doses of her home ziprasidone and topiramate clostridium difficile colitis pt noted to have diarrhea and found to have positive cdif on she was initially started po vancomycin and po flagyl and then narrowed to po vancomycin on pt discharged with a plan to complete a day course of po vancomycin for treatment of cdif last day vocal cord paralysis after extubation pt noted to have dysphonia and aspiration on bedside swallow pt seen by ent who noted left sided vocal cord paralysis started on ppi bid pt to follow up with ent as an outpatient for further management speech and swallow identified aspiration and recommended on puree solids and nectar thick liquids and noted all per oral intake must be done with left head turn with every bite sip oliguric renal failure pt developed oliguric renal failure likely due to hypotension from the massive pulmonary embolism plus contrast injury pt seen by renal consult who noted muddy brown casts urine sediment consistent with atn creatinine peaked at from admission creatinine of pt received hemodialysis for volume and solute clearance from to she developed rapid recovery so hemodialysis was discontinued and the hd line was pulled on creatinine on discharge was she will need outpatient follow up with nephrology bacteremia strep viridans pt febrile on and found to have strep viridans bacteremia strep viridans may be a contaminant however the patient has a reported h o poor dentition and dental pain and temporarily related fever was concerning for true strep viridans bacteremia she was initially on iv vancomycin tte showed no evidence of endocarditis discontinued ceftriaxone and flagyl given no recurrent fevers pt remained afebrile during the rest of the hospitalization and had no subsequent positive blood cultures cystitis pt found to have pan sensitive e coli uti for which she received a course of iv ceftriaxone transaminits pt found to have transaminitis with ast and alt the thousands elevated inr and normal bilirubin and alp her acute hepatitis was likely secondary to ischemic hepatopathy hepatology was consulted resolving on discharge chronic issues t2dm managed with iss during hsopitalization copd continued on home medications hld f u home medications hypothyroidism continued on home levothyroxine transitional issues pt needs to complete a day course of po vancomycin for treatment of cdif last day pt with new vocal cord paralysis for which she is scheduled for ent follow up she was started on pantoprazole 40mg q12h and will need vocal cord injections she will need ct head neck chest with contrast to evaluate the course of the recurrent laryngeal nerve and vagus nerve she is recommended to have modified diet of puree solids and nectar thick liquids and noted all per oral intake must be done with left head turn with every bite sip pt needs outpatient follow up with nephrology with her office can be reached at pt should have outpatient workup for hypercoagulobility predisposition including anti phospholipid antibody syndrome given family history of miscarriages and mother who had an unprovoked dvt pt should undergo age appropriate cancer screening given the concern that pe may be provoked by underlying malignancy pt discharged on coumadin which will be followed by her pcp inr on discharge was she will need repeat inr check on coumadin course is projected to be lifelong given unprovoked vte home statin held given elevated transaminases setting of shock liver this may be restarted the outpatient setting as lfts continue to improve pt s home psychiatric medications were adjusted during hospitalization pt was discharged on her home doses of clonazepam gabapentin perphenazine and prazosin she was started on lower doses of her home ziprasidone and topiramate pt scheduled for follow up with outpatient psychiatrist if pt is interested pursuing partial hospital program she can call arbour counseling at if suicidal thoughts occur pt instructed to call or present to nearest emergency room pt recently discontinued her home metformin she required insulin sliding scale during hospitalization pt should have outpatient consideration of restarting medications for diabetes code full contact daughter hcp on admission the preadmission medication list is accurate and complete ipratropium albuterol inhalation spray inh ih q6h flovent hfa fluticasone mcg actuation inhalation puff 2x day ziprasidone hydrochloride mg po qhs clonazepam mg po bid levothyroxine sodium mcg po daily loratadine mg po daily gabapentin mg po tid perphenazine mg po tid prazosin mg po qhs pantoprazole mg po q12h topiramate topamax mg po bid simvastatin mg po qpm ibuprofen mg po q6h prn pain naproxen mg po q12h prn pain proair hfa albuterol sulfate mcg actuation inhalation q6h prn wheezing discharge medications clonazepam mg po bid rx clonazepam mg tablet s by mouth twice a day disp tablet refills gabapentin mg po tid rx gabapentin mg tablet s by mouth three times a day disp tablet refills levothyroxine sodium mcg po daily prazosin mg po qhs rx prazosin mg capsule s by mouth at bedtime disp capsule refills topiramate topamax mg po bid rx topiramate mg tablet s by mouth twice a day disp tablet refills ziprasidone hydrochloride mg po qhs rx ziprasidone hcl mg capsule s by mouth at bedtime disp capsule refills vancomycin oral liquid mg po q6h rx vancomycin mg capsule s by mouth every six hours disp capsule refills warfarin mg po daily16 rx warfarin mg tablet s by mouth daily disp tablet refills flovent hfa fluticasone mcg actuation inhalation puff 2x day ipratropium albuterol inhalation spray inh ih q6h proair hfa albuterol sulfate mcg actuation inhalation q6h prn wheezing pantoprazole mg po q12h rx pantoprazole mg tablet s by mouth twice a day disp tablet refills perphenazine mg po tid rx perphenazine mg tablet s by mouth three times a day disp tablet refills discharge disposition home with service facility discharge diagnosis primary massive pulmonary embolus acute hypoxic respiratory failure acute tubular necrosis shock liver clostridium difficile colitis complicated cystitis toxometabolic delirium secondary hypothyroidism borderline personality disorder history of suicide attempts post traumatic stress disorder bipolar disorder psychosis anorexia nervosa 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 seen at after being found by your you were found to have a very large blood clot to your lungs this caused you to have low blood pressure and your liver and kidneys sustained some damage from this you required dialysis because of your kidney failure however both your liver and your kidneys recovered and you will not need dialysis for the foreseeable future you will need to follow up with a kidney doctor after your discharge you needed to be intubated so that a breathing machine could help you breathe as the blood clot to your lungs got better you were able to be taken off the machine however after you came off the machine you were found to have paralysis of your vocal cords this is why you have lost your voice you will need to follow up with our ear nose throat ent doctors after your for further management your blood clot improved with blood thinners and you will need to continue on these for the foreseeable future you will continue to take a blood thinner called coumadin aka warfarin you will have to have your coumadin level aka inr monitored frequently and your dose adjusted as needed you were also found to have an infection your large intestine called c diff you were treated with antibiotics for this you need to continue taking vancomycin last day please take all medications as prescribed and please follow up with the appointments we have arranged it is very important that you see your primary care doctor your kidney doctor your psychiatrist and your ent doctor after you leave the hospital to ensure ongoing care do not make any medication changes to your psychiatric medications until you follow up with your psychiatrist if you would like to do a partial program please contact at if you have any feelings that you are unsafe or feel like you are going to harm yourself or others please call or go to the emergency department immediately 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 morphine penicillins attending chief complaint r distal femur periprosthetic fx major surgical or invasive procedure surgical fixation open reduction internal fixation r distal femur history of present illness female hx of chf ef last tte a fib on eliquis who presents after a mechanical fall after slipping on a raw vegetable on the ground at the grocery market she denied head strike or loss of consciousness she denied any presyncopal symptoms she was brought to where her initial evaluation and workup revealed a right periprosthetic distal femur fracture she states that she last took her eliquis the morning of her fall she denies any other complaints including neck pain chest pain shortness of breath pain in the left lower or bilateral upper extremities she states that she ambulates with a cane and is functionally independent of adls and iadls past medical history hypertension cad chf hyperlipidemia hypothyroidism atrial fibrillation social history family history nc physical exam admission physical exam vitals avss general well appearing female in mild distress due to her right thigh pain neck no c spine tenderness or palpable step offs full passive range of motion of the neck right lower extremity skin intact no deformity evident moderate ecchymosis and swelling soft but tender distal thigh and proximal leg full painless rom at bilateral hip left knee and ankle fires silt s s sp dp t distributions pulses wwp discharge physical exam vs po hr rr ra general alert and oriented nad heent sclerae anicteric mmm oropharynx clear neck jvp cm cv irregularly irregular no mrg lungs scattered crackles at bases no wheezes normal respiratory effort gi soft nt nd extremities warm well perfused trace edema on the l ankle edema on the rle neuro no gross motor coordination abnormalities pertinent results admission labs 45pm blood glucose urean creat na k cl hco3 angap 30am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 14am urine hours random urean creat na 30am urine blood neg nitrite neg protein glucose neg ketone tr bilirub neg urobiln neg ph leuks sm discharge labs 16am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 16am blood ptt 16am blood glucose urean creat na k cl hco3 angap 16am blood calcium phos mg imaging venous dup ext uni map no evidence of deep venous thrombosis in the left lower extremity veins imaging knee views right distal femur fracture no definite involvement of the prosthesis radiographically brief hospital course ms is a w hfpef afib on apixiban cad lad in h o sinus pauses and mobitz i avb htn and hypothyroidism admitted with r periprosthetic femur fracture now s p orif course c b bradycardia now improved off carvedilol chf and cardiorenal both improved with diuresis and anemia requiring 1u prbcs acute issues addressed r periprosthetic distal femur fracture the patient was found to have a right distal femur periprosthetic fracture and was admitted to the orthopedic surgery service given her elevated chads2vasc score she was bridged from her home apixaban to a heparin drip for tight control of her anticoagulation status on the way to the operating room the patient was taken to the operating room on for open reduction with internal fixation which the patient tolerated well 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 her home anticoagulation was restarted she received a blood transfusion for an asymptomatic low hematocrit which she tolerated without issue activity restrictions touch down weight bearing in unlocked knee brace on r side recommended discharge to rehab acute on chronic diastolic hf exacerbation likely iv fluid administration and holding diuretics post operatively on lasix 40mg bid at home admission weight 180lbs standing weight was not trended given patient s activity restriction she was treated with iv diuresis with improvement which was transitioned to po diuretics at discharge likely cardiorenal as this developed i s o volume overload cr improved with iv diuresis bradycardia likely to carvedilol as bradycardia improved with discontinuation of medication patient has history of avb 2nd degree type elay previously with hr and pauses on telemetry the patient continued to have episodes of hr in that were asymptomatic after discontinuation of beta blocker non urgent cardiology follow up is recommended for continued surveillance of her asymptomatic bradycardia oral bleeding the patient had hemorrhage from the site of a recent tooth extraction after resuming her home eliquis if this issue recurs she should see her outpatient oral surgeon promptly chronic issues atrial fibrillation continued home apixaban stopped carvedilol as above htn continued home amlodipine hld continued home atorvastatin gerd continued home omeprazole depression continued home citalopram hypothyroidism continued home levothyroxine transitional issues r distal femur periprosthetic fracture f u with orthopedics team in weeks contact information listed above tdwb rle in unlocked brace until ortho follow up consider treatment for presumed osteoporosis with prolia or a bisphosphonate unclear to this author from available records if she has had a bisphosphonate in the past she is continued on vitamin d bradycardia stopped carvedilol because she also has paroxysmal a fib watch for any rvr or palpitations off her beta blocker hfpef if possible to obtain accurate weights with her weight bearing restrictions please trend daily weights please check bmp in one week notify the rehab doctor if creatinine is or higher or if weight changes by five pounds or more titrate po lasix pending volume status tooth bleeding follow up with surgeon who performed recent dental extraction prn code full presumed contact name of health care proxy number medications on admission amlodipine mg po daily atorvastatin mg po qpm carvedilol mg po bid citalopram mg po daily apixaban mg po bid furosemide mg po daily levothyroxine sodium mcg po daily omeprazole mg po daily preservision lutein vit c vit e copper zinc lutein mg unit mg mg oral bid cholecalciferol iu daily discharge medications acetaminophen mg po q8h oxycodone immediate release mg po q4h prn pain moderate do not drink or drive on this medication please beware sedation rx oxycodone mg tablet s by mouth q4hrs disp tablet refills polyethylene glycol g po daily furosemide mg po daily amlodipine mg po daily apixaban mg po bid atorvastatin mg po qpm citalopram mg po daily fluticasone propionate nasal spry nu bid levothyroxine sodium mcg po daily omeprazole mg po daily preservision lutein vit c vit e copper zinc lutein mg unit mg mg oral bid cholecalciferol iu daily this was omitted in error by the discharging resident but was called in to the rehab discharge disposition extended care facility discharge diagnosis primary diagnoses r distal femur periprosthetic fracture acute on chronic diastolic heart failure exacerbation secondary diagnoses anemia constipation bradycardia discharge condition activity status out of bed with assistance to chair or wheelchair mental status clear and coherent level of consciousness alert and interactive discharge instructions dear ms it was a pleasure caring for you at why was i in the hospital 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 what happened to me in the hospital you had a surgery on your r leg you were treated with diuretics for fluid overload you were given a blood transfusion for bleeding you had a kidney injury that improved with diuresis you had slow heart rate that improved with stopping carvedilol you had tooth bleeding that improved what should i do after i leave the hospital continue to take all your medicines and keep your appointments resume your regular activities as tolerated but please follow your weight bearing precautions strictly at all times you also slow heart rate and had volume overload which was treated with diuresis we wish you the best sincerely your team activity and weight bearing touchdown weight bearing in the right lower extremity in an unlocked brace 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 continue to take your apixaban as you were previously 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 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 followup instructions

name unit no admission date discharge date date of birth sex f service surgery allergies amoxicillin iodinated contrast media iv dye iodine lupron lyrica migranal nsaids non steroidal anti inflammatory drug percocet piroxicam salsalate tegretol tylenol codeine ultram vicodin iodoform tegaderm attending chief complaint motor vehicle accident major surgical or invasive procedure none history of present illness year old female presenting to after a motor vehicle accident she was the restrained driver and was hit on the left driver s side while traveling at mph no loss of consciousness no airbag deployment she was seen at an outside hospital where fast showed a pericardial effusion she was transferred to for further management past medical history pmh hypothyroidism psh anterior fusion cervical spine bilateral salpingoophorectomy c section l tendon repair occipital nerve stimulator placed checked social history family history non contributory physical exam admission physical exam vitals hr bp rr sat ra gen nad chest cv rrr no tenderness to palpation lungs ctab abdomen soft nt nd spine tenderness to palpation at base c spine lumbar spine discharge physical exam vitals t97 tm bp hr rr o2 sat o2 delivery ra gen nad aaox3 heent mmm tenderness to palpation left neck cv rrr resp breaths unlabored ctab abdomen soft nondistended nontender ext wwp pertinent results 32pm ptt 32pm plt count 32pm neuts monos eos basos im absneut abslymp absmono abseos absbaso 32pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 32pm asa neg ethanol neg acetmnphn neg tricyclic neg 32pm lipase 32pm urea n 38pm glucose lactate creat na k cl tco2 imaging outside hospital imaging ct head no acute intracranial abnormality post surgical changes of bilateral mastoid occipital region noted with what appears to be implantable meshlike material on the right material thickened relative to left internal gas therefore infection cannot be excluded neurostimulator device is positioned as above ct c spine no fracture seen s p anterior fusion at c5 with c5 disc age disc bulge at c6 posterior spinal stimulator electrodes bilateral craniotomies with possible infected mesh on right ct abdomen moderate sized anterior pericardial effusion electronic implanted device possibly a stimulator unit at posterior right lower thorax mild stranding seen about the paracolic gutters of uncertain etiology imaging ct chest impression essentially normal chest ct no evidence of trauma brief hospital course ms was admitted to the acute care surgery service after being transferred from an outside hospital given concern for pericardial effusion she was fast in the ed but hemodynamically stable she had no additional injuries on imaging obtained at the outside hospital on the night of admission she underwent chest ct which showed an essentially normal chest ct with no evidence of trauma she remained hemodynamically stable she was tolerating a regular diet and ambulating independently she was seen by neurosurgery given the previous neurosurgical procedures and concern for possible infection of the right sided neurostimulator mesh on their evaluation there was no evidence of infection or neurological deficits she was instructed to follow up in clinic and to follow up with her pcp she was therefore discharged home medications on admission the preadmission medication list is accurate and complete levothyroxine sodium mcg po daily lisinopril mg po daily topiramate topamax mg po daily bupropion xl once daily mg po daily fluoxetine mg po daily calcium d calcium carbonate vitamin d3 mg 250mg unit oral daily discharge medications bupropion xl once daily mg po daily calcium d calcium carbonate vitamin d3 mg 250mg unit oral daily fluoxetine mg po daily levothyroxine sodium mcg po daily lisinopril mg po daily topiramate topamax mg po daily discharge disposition home discharge diagnosis motor vehicle accident no significant pericardial effusion discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms you were admitted to after a motor vehicle accident due to concern over fluid around your heart you had a ct of the chest which was normal while in the hospital you were also seen by neurosurgery for your peripheral nerve stimulator there were no signs of infection it is recommended that you follow up with your neurosurgeon dr and with your primary care doctor after discharge please continue all of your home medications please come to the emergency department if you develop fever degrees chills chest pain or shortness of breath dizziness lightheadedness or feeling faint any symptoms that concern you thank you your surgery team 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 right thr failure secondary to fall major surgical or invasive procedure right total hip revision history of present illness male with a fractured right total hip arthroplasty secondary to mechanical trip and fall status post right tha in at transferred to for preoperative optimization and clearance given his diagnosis of moderate to severe pulmonary hypertension past medical history coronary artery disease status post cabg in chronic atrial fibrillation hypertension hyperlipidemia type diabetes mellitus history of right sided cva with resultant left sided weakness treated with thrombolysis prostate cancer 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 aquacel dressing with scant serosanguinous drainage thigh full but soft no calf tenderness strength silt nvi distally toes warm pertinent results 40am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 40am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 40am blood glucose urean creat na k cl hco3 angap 40am blood glucose urean creat na k cl hco3 angap 40am blood calcium phos mg 40am blood calcium phos mg 50am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 05am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 45am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 26am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 21pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 15am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 50am blood plt 05am blood plt ct 45am blood plt 26am blood plt ct 21pm blood plt ct 15am blood plt 15am blood 50am blood glucose urean creat na k cl hco3 angap 05am blood glucose urean creat na k cl hco3 angap 45am blood glucose urean creat na k cl hco3 angap 26am blood glucose urean creat na k cl hco3 angap 15am blood glucose urean creat na k cl hco3 angap 15am blood ck cpk 50am blood ck cpk 15am blood ck mb ctropnt 50am blood ck mb ctropnt 50am blood calcium phos mg 05am blood calcium phos mg 45am blood calcium phos mg 26am blood calcium phos mg 15am blood calcium phos mg 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 the patient was transferred to the for post operative monitoring postoperative course was remarkable for the following the patient was extubated and off pressors prior to arrival to the patient s home metoprolol and imdur were held on admission but metoprolol was restarted post operatively his apixaban was started on pod but at a lower dose of mg x days then he will increase the dose to mg twice daily he otherwise remained stable and was transferred to the floor later that afternoon pod medicine was consulted to assist with co management of the patient they recommended resuming his imdur and continuing to hold his metformin pod his foley was discontinued and he was able to void independently medicine saw the patient and had no new recommendations overnight the patient reported chest pain and took nitroglycerin ekg was performed and showed no changes prior to other ekgs cardiac enzymes were drawn troponin was and medicine recommended that cardiac enzymes be trended pod the patient was confused upon awakening his gabapentin was discontinued second set of troponins were and third set of troponins were medicine did not feel an additional work up was required they felt he was appropriate for discharge with outpatient follow up with his pcp cardiologist his mental status had improved in the afternoon pod patient had complaint of ongoing sternal pain x days with complaint of mild intermittent cough patient remained afebrile a chest x ray was obtained which results were negative for pna patient was not discharged due to observance of pod patient had no further issues prior to discharge and labs remained stable patient to continue apixaban 5mg twice daily x days post op through then may resume home dose 5mg twice daily otherwise pain was controlled with a combination of iv and oral pain medications the surgical dressing will remain on until pod after surgery 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 dressing was intact the patient s weight bearing status is weight bearing as tolerated on the operative extremity with posterior precautions walker or two crutches wean as able mr is discharged to rehab in stable condition medications on admission allopurinol mg po daily apixaban mg po bid atorvastatin mg po qpm vitamin d unit po daily docusate sodium mg po bid fluoxetine mg po daily isosorbide mononitrate extended release mg po daily magnesium oxide mg po daily melatonin mg oral qhs metformin glucophage mg po bid metoprolol succinate xl mg po bid senna mg po bid tamsulosin mg po qhs trazodone mg po qhs prn insomnia discharge medications acetaminophen mg po q8h oxycodone immediate release mg po q4h prn pain allopurinol mg po qhs apixaban mg po bid duration days mg bid until then mg bid atorvastatin mg po qpm increased per cardiology recommendations docusate sodium mg po bid fluoxetine mg po daily isosorbide mononitrate extended release mg po daily magnesium oxide mg po daily melatonin mg oral qhs metformin glucophage mg po bid metoprolol succinate xl mg po bid senna mg po bid tamsulosin mg po qhs trazodone mg po qhs prn insomnia vitamin d unit po daily discharge disposition extended care facility discharge diagnosis right thr failure secondary to fall femoral component separation of the femoral head from the stem 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 please do not take any non steroidal anti inflammatory medications nsaids such as celebrex ibuprofen advil aleve motrin naproxen etc until cleared by your physician anticoagulation please continue your apixaban 5mg twice daily for days through then resume mg twice daily to help prevent deep vein thrombosis blood clots wound care please remove aquacel dressing on pod after surgery it is okay to shower after surgery after days but no tub baths swimming or submerging your incision until after your four week checkup please place a dry sterile dressing on the wound after aqaucel is removed 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 once at home home dressing changes as instructed and wound checks activity weight bearing as tolerated with walker or crutches wean assistive device as able posterior precautions no strenuous exercise or heavy lifting until follow up appointment mobilize frequently physical therapy wbat posterior hip precautions wean assistive device as able mobilize frequently treatments frequency remove aquacel pod after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed followup instructions

name unit no admission date discharge date date of birth sex m service podiatry allergies no known allergies adverse drug reactions attending chief complaint r foot ulcer major surgical or invasive procedure r digit arthroplasty history of present illness this patient is a year old male with pmh significant for uncontrolled type ii diabetes and hypertension with a right fourth to infection patient recalls doing yard work on when he dropped a heavy object on his foot he then travelled to for a business trip and a on noticed an ulcer with increasing redness and drainage on his right fourth toe he presented to an emergency room in where he was admitted for iv antibiotics surgical intervention was discussed during his admission but an infectious disease physician recommended he fly home to and be seen immediately he was discharged on a course of augmentin which he has been taking and states some of the redness has improved patients admits to being diabetic and that his blood sugars have been under poor control his most recent hba1c was he denies any recent nausea vomiting fever chills shortness of breath or chest pain past medical history htn dmii social history family history significant for diabetes and heart disease physical exam admission physical examination general awake alert oriented x3 no acute distress heent mmm neck supple ntac cardiac extremities well perfused lungs no respiratory distress abd soft non tender non distended lower extremity exam pulses palpable b l capillary refill time seconds to the digits b l skin temperature warm to cool from proximal tibia to distal digits bilaterally protective sensation diminished b l ulcer noted to the lateral aspect of the fourth digit that probes deeply scant amount of purulent drainage expressed from the fourth digit ulcer right fourth digit appear erythematous and edematous with sloughing skin erythema note to the right fourth toe extending to the right dorsal foot outline by previous hospital distal aspect of the fourth digit appears dusky in color without capillary refill mild tenderness with palpation of the right fourth digit discharge physical exam pertinent results 29pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 29pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 29pm blood plt 29pm blood glucose urean creat na k cl hco3 angap 29pm blood calcium phos mg 29pm blood crp right foot radiograph findings soft tissue swelling at the fourth toe is present no overt bone destruction or periosteal reaction mild degenerative changes are seen at the first mtp joint fourth tmt joint first tmt joint plantar and posterior calcaneal spurs are seen bipartite lateral sesamoid at first mtp impression soft tissue swelling at the fourth toe no overt evidence of osteomyelitis additional findings as above brief hospital course the patient was admitted to the podiatric surgery service from clinic on for a r foot infection on admission he was started on broad spectrum antibiotics the patient was brought to the operating room on for a right digit arthoplasty which the patient tolerated well for full details of the procedure please see the separately dictated operative report the patient was taken to the pacu in stable condition and was transferred back to the floor after satisfactory recovery from anesthesia throughout his hospital stay the patient remained afebrile with stable vital signs pain was well controlled oral pain medication on a prn basis the patient remained stable from both a cardiovascular and pulmonary standpoint he was placed on broad spectrum antibiotics while hospitalized and discharged with oral antibiotics his intake and output were closely monitored and noted to be adequate the patient received subcutaneous heparin throughout admission early and frequent ambulation were strongly encouraged the patient had hyperglycemia throughout his stay and was seen by a member of the diabetes team and his blood glucose levels improved the patient was subsequently discharged to home on pod with vital signs stable and vascular status intact to right foot the patient received discharge teaching and follow up instructions with understanding verbalized and agreement with the discharge plan medications on admission metformin 1000mg bid lisinopril 40mg simvastatin 40mg discharge medications acetaminophen mg po q6h prn pain mild ciprofloxacin hcl mg po q12h rx ciprofloxacin hcl mg tablet s by mouth twice a day disp tablet refills doxycycline hyclate mg po q12h rx doxycycline hyclate mg tablet s by mouth twice a day disp tablet refills glargine units dinner humalog units breakfast humalog units lunch humalog units dinner insulin sc sliding scale using hum insulin rx insulin glargine lantus solostar unit ml ml as dir units before dinr disp syringe refills lisinopril mg po daily metformin glucophage mg po bid simvastatin mg po qpm discharge disposition home discharge diagnosis r foot ulcer discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions mr it was a pleasure taking care of you at you were admitted to the podiatric surgery service for your right foot surgery you were given iv antibiotics while here you are being discharged home with the following instructions activity there are restrictions on activity please remain weight bearing to your r heel in a surgical shoe until your follow up appointment you should keep this site elevated when ever possible above the level of the heart no driving until cleared by your surgeon please call us immediately for any of the following problems redness in or drainage from your leg wound s new pain numbness or discoloration of your foot or toes watch for signs and symptoms of infection these are a fever greater than degrees chills increased redness or pus draining from the incision site if you experience any of these or bleeding at the incision site call the doctor exercise limit strenuous activity for weeks no heavy lifting greater than pounds for the next days try to keep leg elevated when able bathing showering you may shower immediately upon coming home but you must keep your dressing clean dry and intact you can use a shower bag taped around your ankle leg or hang your foot leg outside of the bathtub avoid taking a tub bath swimming or soaking in a hot tub for weeks after surgery or until cleared by your physician medications unless told otherwise you should resume taking all of the medications you were taking before surgery remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet check with your physician if you have fluid restrictions if you feel that you are constipated do not strain at the toilet you may use over the counter metamucil or milk of magnesia appetite suppression may occur this will improve with time eat small balanced meals throughout the day diet there are no special restrictions on your diet postoperatively poor appetite is not unusual for several weeks and small frequent meals may be preferred follow up appointment be sure to keep your medical appointments if a follow up appointment was not made prior to your discharge please call the office on the first working day after your discharge from the hospital to schedule a follow up visit this should be scheduled on the calendar for seven to fourteen days after discharge normal office hours are through please feel free to call the office with any other concerns or questions that might arise followup instructions

name unit no admission date discharge date date of birth sex f service neurosurgery allergies no known allergies adverse drug reactions attending chief complaint cervical stenosis with spinal cord compression major surgical or invasive procedure c3 c7 laminectomies and posterior fusion history of present illness is a year old female who presented to the emergency department on as a transfer from an outside facility status post motor vehicle collision with complaints of generalized numbness and weakness the patient was transferred to for further evaluation and management mri of the cervical spine in the emergency department was concerning for cervical stenosis with spinal cord compression the neurosurgery service was consulted for question of acute neurosurgical intervention past medical history hyperlipidemia hypertension social history family history noncontributory physical exam on admission vital signs t 1f hr bp rr o2sat on room air general well nourished in cervical collar extremities warm and well perfused neurologic mental status awake and alert cooperative with exam normal affect orientation oriented to person place and date motor deltoid biceps triceps wrist extension wrist flexion grip right4 left4 ip quadriceps hamstring at gastrocnemius right2 left2 sensation intact to light touch and pinprick but complaining of diffuse numbness reflexes right biceps reflex unable to elicit left biceps reflex patellar reflexes bilaterally toes mute proprioception intact rectal tone intact no sign bilaterally no clonus bilaterally on discharge opens eyes x spontaneous to voice to noxious orientation x person x place x time follows commands simple x complex speech fluent x yes no comprehension intact x yes no motor trapezius deltoid biceps triceps grip wf we right5 left5 ip quadriceps hamstring at gastrocnemius right5 left5 x sensation intact to light touch pertinent results please see record for relevant laboratory and imaging results left shoulder xray study date of am impression calcific tendinosis of the supraspinatus infraspinatus minimal degenerative changes in the left shoulder no acute fracture or dislocation radiology report non trauma views study date of impression there is posterior fusion hardware from c3 to c7 no hardware related complications are seen there are degenerative changes with loss of intervertebral disc height at several levels and worse at c3 c4 and c4 c5 lung apices are grossly clear radiology report bilat lower ext veins study date of am impression no evidence of venous thrombosis unilat up ext veins us right study date of impression no evidence of deep vein thrombosis in the right upper extremity radiology report mr cervical spine w o contrast study date of am impression status post bilateral laminectomy and posterior fusion at c3 c7 with expected postsurgical changes new focal expansion and increased t2 signal within the cord at the c3 level some degree of underlying myelomalacia is suspected at the c4 level overall improvement in the degree of spinal canal narrowing from c2 c7 with the worst level at c2 displaying mild to moderate spinal canal narrowing mr w o contrast study date of impression motion limited exam prevertebral edema from the craniocervical junction through c5 c6 no clear evidence for anterior longitudinal ligament edema or disruption but evaluation is limited by motion no other evidence for ligamentous edema or bone marrow edema from c3 c4 through c5 c6 there are disc protrusions and endplate osteophytes severely narrowing the spinal canal and compressing the spinal cord at c6 c7 right paracentral disc protrusion endplate osteophytes cause moderate spinal canal narrowing with ventral spinal cord remodeling there is patchy t2 hyperintensity in the cord from c2 c3 through c6 c7 levels which may represent contusion in the setting of trauma versus chronic myelomalacia in the setting of spinal canal stenosis no evidence for acute traumatic injuries in the thoracic or lumbar spine multilevel lumbar degenerative disease spinal canal stenosis is moderate to severe at l4 l5 and moderate at l3 l4 and l5 s1 with crowding of the intrathecal nerve roots there is also mass effect on multiple traversing and exiting nerve roots as detailed above trace left pleural effusion and mild bilateral dependent atelectasis highly distended bladder please correlate clinically whether the patient is able to void brief hospital course year old female with cervical stenosis s p motor vehicle collision with central cord syndrome cervical stenosis with spinal cord compression central cord syndrome the patient was taken emergently to the operating room for a c3 c7 laminectomy and posterior fusion the procedure was uncomplicated please see separately dictated operative report by dr further details a surgical drain was left in place which was subsequently removed on pod the patient was extubated in the operating room and recovered in the pacu she was transferred to the step down unit for close neurologic monitoring her neurologic exam slowly improved postoperatively postoperative x rays of the cervical spine showed no evidence of retained surgical drain or hardware complications on overnight the patient was noted to have worsened weakness on exam a ct of the cervical spine was obtained which was grossly negative but there was significant artifact from the hardware an mri of the cervical spine was also obtained which showed increased t2 signal in cord at c3 c4 but overall improvement in the degree of spinal canal narrowing from c2 c7 her weakness subsequently improved and continued to improve with continued physical and occupational therapy rib fracture acute care surgery was consulted for fracture of the first rib on the left there was no surgical intervention or follow up needed hypoxia the patient required supplemental oxygen on she was subsequently weaned off the supplemental oxygen and her oxygen saturations remained stable on room air for the remainder of her hospitalization right shoulder and wrist pain the patient complained of significant right shoulder pain an x ray of the right shoulder was obtained which showed no definite fracture or dislocation however there was a well corticated rounded density which was thought to reflect sequela of remote injury or calcific tendinitis she also c o significant right wrist pain an ultrasound of the right wrist was negative pain medications were adjusted urinary retention the patient experienced urinary retention postoperatively her foley catheter was discontinued she failed a voiding trial on and catheter was replaced her foley catheter was discontinued again on and she was able to void but still required intermittent straight cath for retention on discharge patient was voiding without difficulty constipation ileus she was started on an aggressive bowel regimen for constipation on the patient was noted to have abdominal distension kub showed postop ileus no nausea vomiting she was made npo limited narcotics and continued on aggressive bowel regimen repeat abdominal xr showed interval improvement on the patient was passing her bowels and her diet was advanced to regular a repeat kub showed interval improvement of the ileus on discharge patient was moving her bowels without difficulty fever uti the patient became febrile postoperatively urinalysis was positive urine culture showed proteus mirabilis uti she was started on ceftriaxone blood cultures were negative chest x ray was negative on discharged there is no evidence of uti or ongoing infection patient is afebrile hyponatremia the patient was hyponatremic and was started on sodium chloride tablets on with improvement on the patient s serum na level remained low and the salt tablets were increased the serum na level normalized on and the sodium was monitored closely on the salt tablets were titrated down to 1g three times daily the serum sodium continued to be monitored and was stable on her sodium tablets were weaned off and her serum sodium levels remained stable elevated bun the patient s bun was elevated she received a 500ml normal saline bolus on with improvement the bun returned to normal range on her bun was elevated on and returned to normal limits the next day left shoulder pain patient developed severe left shoulder pain ibuprofen was started with some relief xr on showed no fracture or dislocation but did show mild calcific tendinitis ibuprofen was increased and continued was recommended disposition physical therapy and occupational therapy were consulted and recommended discharge to rehabilitation however the patient s health insurance does not provide any rehabilitation benefits family training was done inpatient to work towards a safe discharge social work was consulted given her limited health insurance a family meeting was organized that resulted in the patient s family working to get the patient insurance so benefits can be obtained the goal was to obtain benefits for acute rehab at the recommendation of physical therapy either through the or a second family meeting was held where her son was given power of attorney and health care proxy status as the family worked on insurance patient was approved for health insurance on she was discharged on to for further care medications on admission hydrochlorothiazide 5mg by mouth once daily lisinopril 40mg by mouth once daily discharge medications acetaminophen mg po q6h prn pain mild bisacodyl mg po pr daily prn constipation first line docusate sodium mg po bid fleet enema mineral oil aily prn constipation gabapentin mg po tid heparin unit sc bid ibuprofen mg po q8h prn pain moderate reason for prn duplicate override alternating agents for similar severity lidocaine patch ptch td qam polyethylene glycol g po daily prn constipation third line polyethylene glycol g po daily senna mg po bid simethicone mg po qid prn gas pain hydrochlorothiazide mg po daily lisinopril mg po daily discharge disposition extended care facility discharge diagnosis cervical stenosis with spinal cord compression urinary tract infection ileus post operative pain electrolyte abnormalities rib 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 discharge instructions cervical spinal fusion surgery do not apply any lotions or creams to the site call your surgeon if there are any signs of infection like redness fever or drainage activity we recommend that you avoid heavy lifting running climbing or other strenuous exercise until your follow up appointment you make take leisurely walks and slowly increase your activity at your own pace try to do too much all at once no driving while taking any narcotic or sedating medication no contact sports until cleared by your neurosurgeon do not smoke smoking can affect your healing and fusion medications please do not take any blood thinning medication plavix coumadin until cleared by the neurosurgeon you are cleared to take aspirin and ibuprofen if indicated you may use acetaminophen tylenol for minor discomfort if you are not otherwise restricted from taking this medication when to call your doctor at for severe pain swelling redness or drainage from the incision site fever greater than degrees fahrenheit new weakness or changes in sensation in your arms or legs followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies multihance attending chief complaint referred from clinic for hypertensive urgency major surgical or invasive procedure none history of present illness woman with long standing history of hypertension currently non compliant with home medications hyperparathyroidism and depression presenting from clinic for blood pressure to 160s patient reports long history of treatment for hypertension but has not been compliant with her medications as they often make her feel fatigued notes intermittent mild headaches for which she will occasionally take amlodipine on a prn basis further notes a few episodes of chest discomfort in past several weeks recent episode of nocturnal dyspnea which she attributes to sleep apnea however no current symptoms of headache visual disturbance chest pain or dyspnea feeling well overall and eager to attend her own wedding on in the ed vital signs were ra labs notable for negative troponin x1 ekg with evidence of lvh t wave inversions in precordial leads and avl ua rbc received captopril mg past medical history htn ckd stage ii migraines variant arterial anatomy pancreatic divisum hyperparathyroidism vit d deficiency pth depression social history family history notable for mother with pheochromocytoma in s p adrenal resection physical exam admission exam vitals temp po hr bp rr o2 sat o2 delivery ra general well appearing woman in no acute distress comfortable aaox3 heent normocephalic atraumatic eomi mmm cardiac regular rate rhythm normal s1 s2 holosystolic murmur over the left upper sternal border pulmonary clear to auscultation bilaterally breathing comfortably on room air abdomen soft non tender non distended extremities warm well perfused non edematous discharge exam vitals temp po hr bp rr o2 sat o2 delivery ra general well appearing woman in no acute distress comfortable aaox3 heent normocephalic atraumatic eomi mmm cardiac regular rate rhythm normal s1 s2 holosystolic murmur over the left upper sternal border pulmonary clear to auscultation bilaterally breathing comfortably on room air abdomen soft non tender non distended extremities warm well perfused non edematous pertinent results labs 19am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 19am blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 19am blood plt 19am blood glucose urean creat na k cl hco3 angap 19am blood alt ast alkphos totbili 19am blood ctropnt 19am blood albumin calcium phos mg 44am urine color straw appear clear sp 44am urine blood mod nitrite neg protein glucose neg ketone neg bilirub neg urobiln neg ph leuks neg 44am urine rbc wbc bacteri none yeast none epi 44am urine mucous rare 44am urine ucg negative micro ucx pending brief hospital course woman with long standing history of severe primary hypertension non compliant with medications was admitted for hypertensive urgency responded well to po captopril transitioned to resume home chlorthalidone and amlodipine given strong patient preference and absence of end organ damage was discharged same day with plan for close outpatient follow up hypertensive urgency referred to ed from clinic for incidentally noted bp 160s without associated symptoms although patient does have recent symptoms of intermittent mild chest pain and possible dyspnea which are concerning for previously un recognized hypertensive emergency they are not actively occurring at time of presentation or during admission no evidence of acute end organ damage workup included ekg with lvh but no evidence of active ischemia troponin negative of note patient has had extensive workup for secondary hypertension including mri to evaluate for renal artery stenosis borderline urine metanephrines with normal serum unremarkable head imaging reassuring renin angiotensin levels the degree of current hypertension is due to medication non adherence previously on meds not taking any consistently now and responded well to captopril given strong patient preference to leave hospital and in the absence of symptoms or end organ damage it was reasonable for same day discharge with plan to resume her prior medications of amlodipine and chlorthalidone with close outpatient follow up transitional issues re started chlorthalidone 25mg daily re started amlodipine 10mg daily patient was noted to have systolic murmur at left upper sternal border ii vi please continue to monitor consider echo if needed ua with rbc consider repeat as outpatient consider referral to maternal fetal medicine given very high risk pregnancy with current blood pressures medications on admission the preadmission medication list is accurate and complete amlodipine mg po daily chlorthalidone mg po daily clonidine mg po bid losartan potassium mg po daily discharge medications amlodipine mg po daily chlorthalidone mg po daily held clonidine mg po bid this medication was held do not restart clonidine until you discuss with your pcp held losartan potassium mg po daily this medication was held do not restart losartan potassium until you discuss with your pcp home discharge diagnosis primary essential hypertension secondary delayed menses 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 why you were admitted you had a very high blood pressure at urgent care earlier today and sent to the emergency department there was concern given you had recently had chest discomfort and this may be due to your blood pressure what was done during your hospitalization you were given medications to help lower your blood pressure you were monitored for a short time with improved blood pressures you were asked to stay overnight to observe your blood pressures and make sure they came down to a normal level however you wanted to leave the hospital against our recommendation and you were started on two medications to take for your blood pressure every day what you should do after you leave the hospital please take your blood pressure medications every day this is important to help prevent strokes heart attacks heart dysfunction and serious complications of the kidneys and eyes please limit the amount of salt in your diet do not add salt to foods please follow up with your primary care physician in the next week to have your blood pressure checked and your medications adjusted as necessary we wish you the best your care team followup instructions

name unit no admission date discharge date date of birth sex m service psychiatry allergies no known allergies adverse drug reactions attending chief complaint i am scared of something major surgical or invasive procedure none history of present illness for further details of the history and presentation please see omr including dr initial consultation note dated and dr staff consultation note dated briefly this is a year old single employed refugee man with reported history of extensive trauma tortured during imprisonment in for days daily cannabis use no formal psychiatric history or suicide attempts who presented to ed via ems due to paranoia upon initial interview patient reported was here because he felt scared and believes the fbi and cia were after him although he had no idea why they would be after him patient reported that he was born in and moved with his family to when he was young stated that since at the age of he became involved in politics and protested against the government resulting in him being shunned by his community and family in he was arrested and has been arrested for a total of times patient was given refugee status in by an international organization and came to the in when he arrived to the he was questioned by the fbi and has been questioned by the fbi numerous time with last time being months ago patient reportedly received his green card days prior to presentation mr reported he had been doing well until four months ago after listening to album which resonated with him since then he has been suffering from insomnia constant flashbacks he reports that everything starts with a in his life he was in jail times this started months ago and he tried to graduate high school times patient also reported difficulty with memory difficulty concentrating and visual hallucinations of future war denied ah si hi denied low mood feelings of hopelessness helplessness worthlessness patient also reported that on the day prior to presentation he and his friend who is an refugee took an impulsive trip to to celebrate the patient getting his green card this morning the friend asked him to join him to come to an appointment the friend was very vague about the purpose of the appointment and patient was asked to wait in the car or cafeteria patient saw the meeting and noted that there was fbi paperwork and determined that his friend was sharing information with the fbi about their trip to yesterday as part of an investigation on the patient he also reports that he saw lots of cash in the friend s car which was scary he reports that he does not trust this friend and does not want this writer to call him on interview with dr patient was noted to be a limited historian and was notably ruminative about feeling suspicious and paranoid about others describing a felt energy which no one else can feel reported he was feeling others were colluding with the fbi and cia to come after him and then told a loose rambling narrative about feeling music that i have never felt before and experiencing an expansive mood noted to be restless on examination with expansive affect with accelerated thought process tangential on examination with looseness of associations per collateral obtained from the patient s case manager at who had known him for years but was no longer working with him she reported the patient is high functioning at baseline and has been working for the organization and attending events he was originally taken out of prison in by and international who gave him hours to pack his things and move to he later came to as a political refugee in and was questioned by the fbi upon entrance and they continued to question him for a while he was eligible for a green card in but he didn t get it until two days ago he was at the survivors of torture program at but stopped going and stopping taking his medications unclear dx and medications this year he has been intermittently self medicating by binge drinking and then going on health sprees by doing cleanses and going to the gym obsessively called today stating that he needed the president s phone number and was extremely perseverative he was under the belief that his friend who is an refugee is working for the fbi he has been getting increasingly paranoid for the past several months he has been fixated on rap music and its meaning on the phone today patient mentioned being scared and having thoughts of wanting to return to to get away from the fbi is concerned that patient has the ability and means to do this and that he may not be able to return to the if he goes to even though living in is what he has wanted for all this time and he finally got his green card patient also somewhat impulsively took a day trip to yesterday which is unlike him ed course patient was agitated in the ed noted to be standing in front of the door to his room with four staff members attempting to calm him down patient stated he needed to leave the hospital and go to court stating i am not safe in this hospital i need to go to a different hospital patient asked the psychiatry resident to tell everyone he needs to leave and wanted to speak to the doctor responsible for keeping me here against my will stated that everyone in the hospital will get into trouble if he brings his lawyer in stating you don t want my people to come here patient was seen later in the day for escalating agitation and received a chemical restraint with haldol mg im ativan mg im patient interviewed in team and was notably pleasant with this interviewer but had a difficult time relaying a completely coherent history he reported he had been doing great but then went on to state that although not much had been going on that everyone in my life had been dealing with some kind of depression reported he came to the ed because he was feeling a little scared he then went on to state that he wanted to leave because i have been here four business days he admitted to calling and when asked why he stated i came to the in as a refugee he stated the fbi had bothered me too many times they questioned me saying they wanted to have coffee and tea with me asking me about politics and i wasn t feeling comfortable patient reported this had been going on for the past years and stated that on the day of presentation he had been out with his best friend i found out he was in a meeting with the fbi about me reporting it made him feel depressed and scared if you don t trust me why would you let me in this country reported he doesn t feel trusted in the and that it is unwelcoming in this country mr reported that he currently lives in with his roommates who are also refugees stated he spends his time working taking care of himself and going shopping reported he was currently working at the and that had been going well patient denied depressed mood stating he has been feeling very good for the past four months he confirmed that four months ago he was listening to record and stated this changed my thinking i learned that you shouldn t let someone old you down he then went on to talk about always facing god i have my own feeling with god he then talked about following the number four it s the number where i find links was number and he was the first black man to play baseball i go back and see and everything in politics is planned that way i m trying to understand this country he then went on to state that he had died four times had been in four countries that there are four letters in his first name and that he speaks four languages and that he has four brothers stated that he had a child pass away years and months ago denied frank grandiosity but stated that i m feeling more strong than yesterday and stronger everyday my confidence is special on psychiatric review of systems patient denied depressed mood endorsed good sleep approximately hours per night reported good energy and concentration beautiful appetite denied suicidal ideation or homicidal ideation denied avh denied history of decreased need for sleep hypersexuality denied anxiety on my examination but did state that he had history of flashbacks in the past but denied they were bothering him at this time reported history of nightmares of the fbi out to get him denied alcohol use but admitted to cannabis use stating he smokes it about per week past medical history past psychiatric history prior diagnoses denies hospitalizations denies current treaters and treatment none medication and ect trials trazodone groggy suicide attempts denies self injurious behavior denies harm to others denies access to weapons denies past medical history back and shoulder pain head injuries from being tortured in prison denies history of seizures social history substance use history alcohol denies alcohol x months used to drink sleep prior tobacco ppd caffeine shots of espresso daily other illicit substances and ivdu mj daily x months denies daily use on my exam personal and social history per omr patient born and raised in to a family as the oldest of with brothers and sisters he reported growing up in was difficult as he was treated like a second class citizen stated his father and mother both worked for the as patient reported that he began protesting the regime because i did not feel right not being a free man stated he did not complete high school due to incarcerations for protesting reported he had gone on a hunger strike for days which was a human rights violation stated that the times got a hold of his story and he was able to get out of the patient also reported that in he had been dating a girl when he as about years old but that her father would not let her marry him patient reported she became pregnant and her father forced her to have an abortion patient reportedly came to the in as noted above denies legal issues since arriving to the and received his green card days prior to presentation stated he had been dating a girl until recently and that she had become pregnant and had an abortion as well when asked how this affected him he stated the lord giveth and the lord taketh currently reportedly working in with roommates and working at although his former case manager states he was working at the same as her denies access to guns family history family psychiatric history history of psychiatric disorders denies history of suicide attempts denies history of substance use denies physical exam vital signs t98 bp hr rr spo2 exam general heent normocephalic atraumatic moist mucous membranes oropharynx clear supple neck no scleral icterus cardiovascular regular rate and rhythm s1 s2 heard no murmurs rubs gallops distal pulses throughout pulmonary no increased work of breathing lungs clear to auscultation bilaterally no wheezes rhonchi rales abdominal non distended bowel sounds normoactive no tenderness to palpation in all quadrants no guarding no rebound tenderness extremities warm and well perfused no edema of the limbs skin no rashes or lesions noted neurological 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 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 and tone bilaterally no abnormal movements no tremor strength throughout sensory no deficits to fine touch throughout dtrs and symmetrical throughout coordination normal on finger to nose test no intention tremor noted gait good initiation narrow based normal stride and arm swing able to walk in tandem without difficulty romberg absent cognition wakefulness alertness awake and alert attention days of the week backwards with errors orientation oriented to person time place situation executive function go no go luria trails fas not tested memory out of registration out of recall after grossly intact fund of knowledge consistent with education intact to last presidents calculations quarters abstraction interprets the grass is always greener on the other side as as the grass something going on the other side is more green and you cannot judge a book by its cover as you cannot know what is inside book you need to look inside to understand visuospatial not assessed language native speaker speaks well however does report that he is more comfortable with aerobic and no paraphasic errors appropriate to conversation mental status appearance man appearing stated age well groomed wearing hospital gown in no apparent distress behavior sitting up in interview chair appropriate eye contact psychomotor agitation of bouncing his legs attitude cooperative engaged friendly for the most part however does become more irritable when talking about staying in the hospital or usage of his electronics to speak with his family mood i am great affect flat affect full range labile at times not congruent with mood speech normal rate volume and tone thought process linear coherent goal oriented no loose associations thought content safety denies si hi delusions patient shares concerns for the fbi and cia he also shares ideas of reference that the television and the radio are sharing information related to the conditions in the no evidence based on current encounter hallucinations denies avh not appearing to be attending to internal stimuli insight limited judgment poor mental status exam appearance man appearing stated age well groomed wearing grey sweater and sweatpants in no apparent distress behavior sitting up in interview chair intense eye contact at times speech rapid but interruptible no psychomotor agitation attitude cooperative engaged friendly mood fantastic affect expansive affect mood congruent speech normal rate volume and tone thought process linear at times circumstantial no loose associations thought content safety denies si hi delusions no longer endorsing preoccupations with being monitored by government obsessions compulsions no evidence based on current encounter hallucinations denies avh not appearing to be attending to internal stimuli insight limited judgment fair discharge examination vs a b appears stated age dressed casually with good hygiene and grooming calm cooperative with interviewer good eye contact no psychomotor agitation or retardation noted s normal rate volume prosody m good a hyperthymic inappropriate to situation tc denies si hi avh tp linear goal and future oriented c awake alert and oriented x3 i j improved improved pertinent results na k cl co2 bun creat glucose wbc rbc hgb hct mcv mch mchc rdw plt count neuts lymphs monos eos basos absneuts benzodiazepine barbiturate neg opiate neg cocaine neg amphetamine neg methadone neg brief hospital course this is a year old single employed male refugee with reported history of extensive trauma tortured during imprisonment in for days daily cannabis use no formal psychiatric history or suicide attempts who presented to ed via ems due to paranoia history and presentation notable for a profound history of reported trauma with numerous incarcerations for political activity and immigration to in but without formal psychiatric history until recently with patient reporting approximately months of symptoms after listening to album history is concerning for underlying and paranoia that the fbi and cia are out to get him patient reportedly has been questioned by the fbi in the past but patient is now paranoid his friends are being questioned with thoughts of fleeing to in order to escape this perceived persecution unable to confirm his story at this time collateral from his former case manager concerning for increasing paranoia with patient recently perseverting on obtaining the president s phone number impulsivity going to with his friend without apparently planning this trip which appears to be out of character for him ed course notable for expansive mood with periods of irritability and agitation requiring chemical restraint mental status examination on admission was concerning for mania with psychotic features patient appears well groomed but is notably hyperthymic and expansive with rapid speech thought process that is notable for derailments tangentiality looseness of associations and thought content that is concerning for ideas of reference and paranoid delusions that likely have some basis in reality diagnostically given his young age and presentation i am concerned for an affective psychosis at this time particularly bpad type i manic with psychotic features however his cannabis use may very well be contributing to his current presentation and i cannot rule out substance induced psychosis mania at this time given his young age and good health an underlying medical condition is unlikely to be contributing to his current presentation given lack of negative symptoms apparent lack of prodromal phase i think that a primary psychotic disorder such as schizophrenia is further down on the differential of note although the patient has a history of trauma and ptsd symptoms he does not appear anxious dysphoric or distressed on my examination i do not believe is presentation is due to untreated ptsd or anxiety symptoms although certainly he is at high risk for anxiety disorders legal safety patient admitted to on a upon admission he declined to sign a conditional voluntary form stating he did not want to be in the hospital he maintained his safety throughout his hospitalization on minute checks and did not require physical or chemical restraints given lack of evidence of threat to self others or inability to care for self with patient able to attend to adl s independently we did not feel he met criteria to file a 8b particularly as he was willing to follow up with outpatient treaters bpad currently manic with psychotic features patient declined additional medical workup including b12 folate tsh rpr lft s metabolic panel stating he had already had enough blood drawn after discussion of the risks and benefits we offered the patient risperidone mg po qhs and mg po tid prn agitation in addition to ativan mg po prn however patient consistently declined this medication stating he did not feel he needed it noted to somewhat paranoid during his hospitalization stating he felt his friend was forced by the fbi to put cameras in his room and that his friend was recording his conversations mental status examinations were notable for ongoing paranoia preoccupation with the number with magical thinking surrounding this number cheerful but intense affect and consistent denial of suicidal ideation or thoughts of self harm of note patient was seen by dr medical director of the inpatient unit and dr vice chair of the department of the psychiatry both clinicians agreed with likely diagnosis of psychosis and paranoia with assessment that it would be reasonable to discharge with referral to outpatient supports upon the expiration of his on day of discharge the patient reported he was looking forward to returning home and following up with physical therapy for a shoulder injury denied si hi avh on examination with thought process that was linear goal and future oriented ptsd with patient reporting history of flashbacks and nightmares unclear if he has truly been diagnosed with this in the past patient declined medications during this admission with no complaints of ptsd symptoms cannabis use see above patient inconsistent in how much mj he is using patient as educated on the deleterious effects of cannabis on his mental health and stated he was planning on abstaining from cannabis once discharged as he felt this was contributing to his paranoia medications on admission the preadmission medication list is accurate and complete this patient is not taking any preadmission medications discharge medications nicotine polacrilex stck po q1h prn nicotine craving discharge disposition home discharge diagnosis bipolar affective disorder with psychotic features cannabis use disorder discharge condition vs a b appears stated age dressed casually with good hygiene and grooming calm cooperative with interviewer good eye contact no psychomotor agitation or retardation noted s normal rate volume prosody m good a hyperthymic inappropriate to situation tc denies si hi avh tp linear goal and future oriented c awake alert and oriented x3 i j improved improved discharge instructions please follow up with all outpatient appointments as listed take this discharge paperwork to your appointments please continue all medications as directed please avoid abusing alcohol and any drugs whether prescription drugs or illegal drugs as this can further worsen your medical and psychiatric illnesses please contact your outpatient psychiatrist or other providers if you have any concerns please call or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers it was a pleasure to have worked with you and we wish you the best of health we strongly recommend engaging in aa na smart recovery meetings for ongoing help with sobriety here is a website with links to meetings near your area followup instructions

name unit no admission date discharge date date of birth sex f service cardiothoracic allergies amitriptyline hydrochlorothiazide lisinopril attending chief complaint left arm discomfort and shortness of breath major surgical or invasive procedure coronary artery bypass grafting x2 with the left internal mammary artery to the left anterior descending artery and reverse saphenous vein graft to the third obtuse marginal artery history of present illness year old speaking female who has been experiencing a left arm discomfort that radiates from her forearm to her chest she states she has had it with exertion and also while in church her chest pain is also associated with shortness of breath the day prior to admission she had arm pain that lasted all day long she came in to see dr she was referred to the for further evaluation she had a stress test that was found to be abnormal and admitted for a cardiac catheterization during catheterization she was found to have lad disease and occluded lcx which had a successful poba she is now being referred to cardiac surgery to evaluate for surgical revascularization past medical history coronary artery disease type diabetes hyperlipidemia hypertension gerd sleep apnea no cpap thyroid nodule anxiety depression past surgical history thyroidectomy l lobe hemithyroidectomy for nodule lipoma removal from back and left groin bladder suspension social history family history mom died suddenly at age they said because of hypertension working in the of her dad had a murmur physical exam pulse resp o2 sat ra b p right 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 murmur grade abdomen soft x non distended x non tender x bowel sounds x extremities warm x well perfused x edema varicosities none x neuro grossly intact x pulses femoral right palp left palp dp right palp left palp right palp left palp radial right palp left palp carotid bruit none noted right left pertinent results 52am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 22am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 12am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 52am blood glucose urean creat na k cl hco3 angap 22am blood glucose urean creat na k cl hco3 angap 12am blood glucose urean creat na k cl hco3 angap 49pm blood k 14am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 32pm blood hct 49pm blood k 37pm blood glucose urean creat k 14am blood glucose urean creat na k cl hco3 angap 32pm blood k 23pm blood urean creat cl hco3 angap tee pre cpb the left atrium is mildly dilated the left atrial appendage emptying velocity is depressed 4m s no atrial septal defect is seen by 2d or color doppler there is mild symmetric left ventricular hypertrophy the left ventricular cavity size is normal overall left ventricular systolic function is normal lvef the calculated cardiac output by continuity equation is l min right ventricular chamber size and free wall motion are normal no thoracic aortic dissection is seen the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic stenosis no aortic regurgitation is seen the mitral valve leaflets are mildly thickened mild mitral regurgitation is seen post cpb biventricular systolic function is preserved the lvef is the calculated cardiac output is 1l min the mr remains mild other valvular function remains unchanged there is no evidence of aortic dissection brief hospital course the patient was brought to the operating room on where the patient underwent coronary artery bypass grafting x2 with the left internal mammary artery to the left anterior descending artery and reverse saphenous vein graft to the third obtuse marginal artery 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 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 were left in an extra day due to drainage and air leak chest tubes were pulled pod2 and pacing wires were discontinued without complication the patient was evaluated by the physical therapy service for assistance with strength and mobility she did have a fever of urine culture was pending at the time of discharge and will be followed up as an outpatient wbc remained normal 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 amlodipine mg po daily atorvastatin mg po qpm losartan potassium mg po daily naproxen mg po q12h prn pain moderate temazepam mg po qhs prn insomnia aspirin ec mg po daily metformin glucophage mg po bid discharge medications acetaminophen mg po pr q4h prn pain or temperature docusate sodium mg po bid furosemide mg po daily duration days rx furosemide lasix mg tablet s by mouth daily disp tablet refills hydromorphone dilaudid mg po q4h prn pain mild reason for prn duplicate override alternating agents for similar severity rx hydromorphone mg tablet s by mouth q hours disp tablet refills metoprolol tartrate mg po bid rx metoprolol tartrate mg tablet s by mouth twice a day disp tablet refills polyethylene glycol g po daily potassium chloride meq po daily duration days rx potassium chloride meq tablet s by mouth daily disp tablet refills atorvastatin mg po qpm rx atorvastatin lipitor mg tablet s by mouth q disp tablet refills amlodipine mg po daily aspirin ec mg po daily bupropion sustained release mg po bid losartan potassium mg po daily metformin glucophage mg po bid do not resume until naproxen mg po q12h prn pain moderate temazepam mg po qhs prn insomnia discharge disposition home with service facility discharge diagnosis coronary artery disease type diabetes hyperlipidemia hypertension gerd sleep apnea no cpap thyroid nodule anxiety depression past surgical history thyroidectomy l lobe hemithyroidectomy for nodule lipoma removal from back and left groin bladder suspension 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 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 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 f service neurology allergies no known allergies adverse drug reactions attending chief complaint acute in pain headache major surgical or invasive procedure conventional angiography history of present illness with pmh htn left breast ca s p mastectomy who presents with headache with hypertensive emergency and found to have ich on imaging patient woke up this morning at 5am with an headache that she described as throbbing bi frontal without radiation she denies any dizziness light headedness visual changes photo phonophobia reports nausea but no vomiting she checked her blood pressure which was in the 200s so she went to the emergency room she took a regular strength tylenol which she states helped alleviate the pain she has never had a ha like this before and rarely gets headaches she states her sbps are normally in but that her pcp recently added hctz to her anti hypertensive regimen at osh sbp noted to be in 200s and patient was started on a nicardipine gtt ct showed ich and patient was transferred to for further management by the time i saw patient she was off nicardipine gtt and sbp s were 140s past medical history htn breast ca s p mastectomy no chemo or radiation therapy social history family history mother with questionable brain disease not fully clarified physical exam physical exam vitals general awake cooperative nad heent nc at no scleral icterus noted mmm no lesions noted in oropharynx cardiac rrr well perfused pulmonary breathing comfortably on room air abdomen soft nt nd extremities no cyanosis clubbing or edema bilaterally radial dp pulses skin no rashes or other 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 are no paraphasic errors able to name both high and low frequency objects able to read without difficulty speech is not dysarthric able to follow both midline and appendicular commands able to register objects and recall at minutes had good knowledge of current events there is no evidence of apraxia or neglect cranial nerves i olfaction not tested ii perrl to 2mm and brisk vff to confrontation and no extinction iii iv vi eomi without nystagmus normal saccades v facial sensation intact to light touch vii no facial droop facial musculature symmetric viii hearing grossly intact to speech ix x palate elevates symmetrically xi strength in trapezii and scm bilaterally xii tongue protrudes in midline and equal strength bilaterally motor normal bulk tone throughout no pronator drift bilaterally no adventitious movements such as tremor noted no asterixis noted delt bic tri wre ffl fe io ip quad ham ta l r sensory no deficits to gross touch throughout no extinction to dss pertinent results 30am glucose urea n creat sodium potassium chloride total co2 anion gap 30am calcium phosphate magnesium 30am wbc rbc hgb hct mcv mch mchc rdw rdwsd 30am neuts monos eos basos im absneut abslymp absmono abseos absbaso 30am plt count 30am ptt year old lady with history of pmh htn left breast ca s p mastectomy in remission who presents with headache with hypertensive emergency found to have left parafalcine ich ich her systolics were to initially her neurologic exam was normal cth showed left cingulate gyrus small ich dsa was negative for aneurysm mri showed likely cavernoma with stable hemorrhage her headache improved with blood pressure control aspirin was held and losartan was increased to mg daily from mg daily she remained stable and was discharged on hd with stable neurologic exam she will need repeat mri in months to assess for vascular abnormality medications on admission the preadmission medication list is accurate and complete aspir aspirin mg oral daily rosuvastatin calcium mg po qpm hydrochlorothiazide mg po daily losartan potassium mg po daily discharge medications losartan potassium mg po daily rx losartan mg tablet s by mouth once a day disp tablet refills hydrochlorothiazide mg po daily rosuvastatin calcium mg po qpm held aspir aspirin mg oral daily this medication was held do not restart aspir until told to resume from a neurologist discharge disposition home discharge diagnosis intra parenchymal hemorrhage discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear came to the hospital because of headache and high blood pressure while were here we found a small bleed on the left side of your brain which is likely due to a cavernoma or small cluster of blood vessels which were probably born with had a special procedure which showed did not have an aneurysm we are changing your medications as follows we are increasing your losartan from mg daily to mg daily to better control your blood pressure this is important to prevent further bleeding we also stopped your aspirin as it can increase your risk of bleeding now that are leaving the hospital we recommend the following please follow up with your doctors as listed below will need to get a repeat mri of your brain in months we wish the best neurology followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies depakote lisinopril topamax ultram hydrochlorothiazide attending chief complaint dyspnea cough headache diarrhea major surgical or invasive procedure colonoscopy and egd history of present illness year old lady with history of htn copd iddm hypothyroidism dvt who presented with diarrhea sob and headache x days found to have severe hyponatremia patient presented for routine pcp check up today but was complaining of shortness of breath diarrhea pounding headache and edema r l x days she reported tan watery diarrhea episodes day not associated with abdominal pain nausea or vomiting she has not had any recent travel or dietary water source changes lives in senior housing so she thinks that maybe half of her apartment complex has diarrhea at baseline her appetite had been poor and additionally reported minimal fluid intake she has continued to take hctz she endorses lightheadedness for the last several days in addition she notes cough ongoing for weeks non productive no fevers no chills she reports dyspnea with difficulty lying flat due to shortness of breath also with progressive edema over the last week and half with rle lle she does have history of dvt many years ago in setting of a tumor removal from her leg initial vitals at pcp office bp pulse temp f c resp spo2 and was sent to for further evaluation at she was noted to have spo2 on ra no focal neurological deficits on exam but edema evaluation there remarkable for na k bun cr lfts wnl bnp tsh upper limit of normal random cortisol negative influenza a b cth and cxr wnl no reports available for review in the ed initial vitals were hr bp spo2 2l nc exam notable for clinically dry no crackles on exam bilateral edema labs notable for wbc hgb plt lactate serum osm uosm na cr pr cr u a wbc rbc few bacteria epi imaging was notable for no new imaging obtained patient was given ml ns bolus review of systems was negative except as detailed above past medical history seizure disorder hypertension copd iddm gerd hyperlipidemia history of dvt social history family history noncontributory physical exam physical exam on admission general pleasant elderly lady breathing comfortably in no acute distress heent mmm no jvd at degrees cardiac normal rate regular rhythm no m r g appreciated pulmonary diffuse expiratory wheezes throughout all lung fields abdomen soft nontender distended obese no fluid wave apprecaited extremities tight edema in bilateral rle lle cap refill 2s skin no rashes appreciated neuro ao x moves all extremities symmetrically and with purpose discharge exam general laying down in bed alert and conversive heent moist mucous membranes no pharyngeal exudates or erythema lungs low lung volumes with minimal air movements clear to auscultation bilaterally cv normal rate regular rhythm no m r g appreciated abdomen abdomen soft nontender nondistended ext no bilateral edema appreciated in lower extremities neuro a ox3 pertinent results labs 57pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 57pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 57pm blood plt 57pm blood glucose urean creat na k cl hco3 angap 57pm blood glucose urean creat na k cl hco3 angap 57pm blood ctropnt 57pm blood probnp 57pm blood totprot calcium phos mg 01pm blood lactate na discharge labs 20am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 20am blood plt 20am blood glucose urean creat na k cl hco3 angap 20am blood calcium phos mg 20am blood iga 20am blood ttg iga pnd studies bilat lower ext veins port study date of no evidence of deep venous thrombosis in the right or left lower extremity veins subcutaneous edema is noted in the calves bilaterally tte mild symmetric biventricular hypertrophy with normal left ventricular cavity size and regional global biventricular systolic function echocardiographic evidence for diastolic dysfunction with elevated pcwp moderate pulmonary artery systolic hypertension with elevated right atrial pressure egd normal mucosa in the whole esophagus esophageal hiatal hernia erosions in the antrum biopsy normal mucosa in the whole examined duodenum colonoscopy normal mucosa in the whole colon random biopsies polyp 4mm in the descending colon polypectomy diverticulosis of the whole colon recommend repeat colonoscopy in years brief hospital course ms is a with history of htn copd iddm hypothyroidism dvt who originally presented with diarrhea sob and headache x days found to have severe hypervolemic hyponatremia that improved with diuresis and discontinuation of her hydrochlorathiazide she was found to have iron deficiency anemia and dysphagia for which she underwent egd and colonoscopy without pertinent findings active issues hypotonic hypervolemic hyponatremia admitted with severe hyponatremia to etiology was mostly hypervolemia due to diastolic heart failure exacerbation and hctz use we d c d hctz and placed a fluid restriction and initiated pharmacologic diuresis with loop diuretics until the patient was euvolemic patient originally had symptomatic headaches confusion and shortness of breath these all improved with diuresis renal was consulted and made recommendations about an outpatient diuretic regimen with torsemide mg po qd the patient s na normalized to by discharge and she was asymptomatic heart failure with preserved ejection fraction patient originally presented with severe bilateral lower extremity edema orthopnea shortness of breath and severely elevated bnp lenis were negative responded well to diuresis as above was euvolemic at discharge discharge weight kg discharge cr anemia hgb remained consistently low with microcytic pattern during admission ferritin was low normal and tibc was high normal patient also described ongoing weight loss and change in stool patterns alternating diarrhea constipation worm like stools last colonoscopy in included removal of polyps and recommendation for follow up colonoscopy in year which patient did not get she received both a colonoscopy and an egd as an inpatient had one colonic polyp removed and random biopsies sent egd was notable for mild gastritis with antral erosions no stricture change in stool habits patient reported days of watery diarrhea prior to admission she also described change in stool formation worm pebble like diarrhea was likely viral gastroenteritis given time course c diff was negative after admission patient was constipated for week this resolved with a bowel prep that was done in preparation of an inpatient colonoscopy to evaluate for iron deficiency anemia see above iga levels and transglutaminase antibodies were sent both negative dysphagia patient complained of discomfort while swallowing during admission was evaluated by speech and swallow who found no oropharyngeal pathology egd showed mild gastritis no evidence of esophageal stricture klebsiella uti patient had ua concerning for infection upon admission speciated to klebsiella was treated with ceftriaxone x days with good result subsequently denied urinary discomfort vulvovaginal candidiasis urinary retention patient had vaginal discharge and inner groin rash consistent with candidiasis responded very well to po fluconazole and miconazole powder pt originally had foley upon admission which was discontinued pt had one day of urinary retention which later resolved likely was due to uti prolonged foley placement hypoxia dyspnea patient had acute on chronic dyspnea during hospitalization has pack year smoking history and copd generally felt with activity cxr without evidence of pulmonary edema pneumonia or pleural effusion lenis negative as above patient s oxygenation improved with 2l nc later weaned to ra she was also given standing duonebs hyperglycemia patient was managed on an insulin sliding scale po anti hyperglycemics were held sore throat patient complained of sore throat that was managed with throat lozenges and chloraseptic spray with good response likely a viral pharyngitis no erythema or exudates on exam hypomagensia patient had hypomagnesmia upon admission that normalized with administration of mgso4 chronic issues history of seizures continued home keppra hypertension home losartan was increased from to mg po qd eventually may benefit from increasing home losartan to mg but holding off currently i s o ongoing diuresis continue metoprolol hyperlipidemia continued home pravastatin diabetes received insulin ssi while in house hypothyroidism continued home levothyroxine mcg transitional issues hfpef patient to be discharged on po torsemide mg qd as maintenance diuretic please adjust prn to maintain weight and euvolemic status discharge dry weight kg discharge cr gi biopsies f u on pathology from colonoscopy random biopsies and polypectomy f u on egd biopsy pathology of antral erosions mild gastritis counsel patient to avoid nsaids given hx of microcytic anemia and gastritis on egd weight loss poor appetite patient should receive age appropriate cancer screening and phq screening as outpatient for follow up for poor appetite and weight loss patient endorsed weakness confusion poor appetite for several weeks prior to admission if this was due to low sodium that had been present for some time she denied symptoms of depression patient noted to have iron deficiency anemia throughout hospitalization colonoscopy and egd revealed one polyp and mild gastritis pt should have follow up for ongoing anemia with monitoring of symptoms greater than hour spent on care on day of discharge code status full limited trial contact son pt s son is alternate medications on admission the preadmission medication list is accurate and complete hydrochlorothiazide mg po daily ibuprofen mg po q12h prn pain mild levothyroxine sodium mcg po daily metformin glucophage mg po bid losartan potassium mg po daily levetiracetam mg po bid fluticasone propionate nasal spry nu bid albuterol inhaler puff ih q4h prn sob pravastatin mg po qpm gabapentin mg po tid metoprolol succinate xl mg po daily omeprazole mg po daily glimepiride mg oral bid aspirin mg po daily discharge medications amlodipine mg po daily heparin unit sc bid ipratropium albuterol neb neb neb q6h sob miconazole powder appl tp tid prn rash multivitamins tab po daily nicotine patch mg day td daily losartan potassium mg po daily albuterol inhaler puff ih q4h prn sob aspirin mg po daily fluticasone propionate nasal spry nu bid gabapentin mg po tid glimepiride mg oral bid levetiracetam mg po bid levothyroxine sodium mcg po daily metformin glucophage mg po bid metoprolol succinate xl mg po daily omeprazole mg po daily pravastatin mg po qpm discharge disposition extended care facility diagnosis primary diagnosis hypervolemic hyponatremia secondary diagnosis iron deficiency anemia constipation vaginal candidiasis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions discharge instructions dear it was a pleasure caring for you at why was i in the hospital you came to the hospital because you had a headache shortness of breath and diarrhea we found that you had very low sodium levels in your blood this is called hyponatremia you also had anemia low blood levels with low iron levels what happened to me in the hospital we gave you diuretics to lower the amount of fluid in your body you got a upper endoscopy and colonoscopy that found some irritation in the esophagus there was one polyp in the colon what should i do after i leave the hospital continue to take all your medicines and keep your appointments we wish you the best sincerely your team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies penicillins enalapril ace inhibitors iodine codeine advair hfa losartan levofloxacin hydrochlorothiazide attending chief complaint respiratory failure major surgical or invasive procedure intubation history of present illness with pmh copd on 3l home o2 dchf cad etoh abuse and schizoaffective disorder who presented with respiratory failure per patient s daughter she was recently discharged from weeks ago after a prolonged week stay during that time she was treated for a copd exacerbation and discharged on a prednisone taper which she finished one week ago her family was also told that she may have had a pneumonia although there was reportedly some disagreement over this diagnosis reportedly recommended rehab but her family decided to take her home since returning home her family has noticed progressive failure to thrive she was able to walk on her own prior to hospitalization but since returning has stayed mostly in bed her activity has been limited by both dyspnea and weakness her family was also concerned that she may have been depressed and was also occasionally confused at there was a concern for aspiration and she was discharged on thickened liquids she ran out of these several days ago per her family she did not have any witnessed aspiration events for the past few days her family noticed that her breathing was getting progressively faster and she looked like she was hyperventilating she appeared diaphoretic but had no known fevers she has a chronic productive cough but is unable to produce sputum on her own this has not recently changed she sleeps on an angled pillow at home which has also not recently changed her nebulizers were helping her breathing but relief was not as long as before today she was working with physical therapy at home and she was noted to be hypoxic to on her home 3l the physical therapist increased her o2 to 4l but she remained hypoxic at that point her daughters called ems ems found her to be in significant respiratory distress and placed her on cpap in the ed she was intubated on arrival for tachypnea in the in the ed initial vitals on fio2 exam notable for severe tachypnea in the labs were notable for lactate ua with glucose but negative ketones leukocytosis of troponin bnp abg post intubation pco2 po2 hco3 tv rr peep fio2 imaging cxr with asymmetric pulmonary edema r l patient was given etomidate rocuronium induction fentanyl midaz sedation 2g iv cefepime 1g iv vancomycin 125mg iv methylprednisolone consults none on arrival to the micu she was sedated and noted to be bradycardic in the she was normotensive past medical history copd 3l home o2 diabetic type etoh abuse tobacco addication diabetic retinopathy cad htn elevated cholesteral schizoaffective d o tardive dyskinesia vertebral compression fx left radial fx hyponatremia thyroid nodule social history family history family history mother heart disease hypertension diabetes anemia sister cancer father tb passed away in daughter physical admission exam vitals fio2 peep general sedated but arousable following commands heent nc at sclera anicteric neck supple jvp difficult to assess given body habitus lungs decreased and coarse breath sounds anteriorly cv bradycardic regular rhythm no murmur rubs gallops abd soft non tender non distended no rebound tenderness or guarding ext warm well perfused trace peripheral edema skin no rashes on limited exam neuro moving all extremities access subclavian pertinent results admission labs 11pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 11pm blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 11pm blood plt 43am blood ptt 11pm blood glucose urean creat na k cl hco3 angap 11pm blood alt ast alkphos totbili 11pm blood probnp 11pm blood albumin calcium phos mg 11pm blood tsh 45pm blood type art rates tidal v peep fio2 po2 pco2 ph caltco2 base xs aado2 req o2 intubat intubated vent controlled 24pm blood lactate imaging cxr impression monitoring and support devices are in appropriate position pulmonary vascular congestion is asymmetrically worse on the right cxr post picc findings single ap portable upright view the chest provided there has been placement of a right subclavian central venous catheter with its tip in the mid svc region the endotracheal tube is again seen with its tip located cm above the carina the ng tube courses below the left hemidiaphragm tip excluded from view right sided interstitial opacity again noted which could reflect asymmetric pulmonary edema the heart is mildly enlarged no pneumothorax lenis findings there is normal compressibility flow and augmentation of the bilateral common femoral femoral and popliteal veins normal color flow is demonstrated in the posterior tibial and peroneal veins there is normal respiratory variation in the common femoral veins bilaterally no evidence of medial popliteal fossa cyst impression no evidence of deep venous thrombosis in the right or left lower extremity veins cxr impression compared to chest radiographs since most recently and moderate cardiomegaly is chronic marked disparity in radiodensity lungs could be due to asymmetric distribution of edema in the setting of emphysema but other explanation should be considered these include acute airway obstruction in the left lung or large unilateral pulmonary embolism interrupting circulation to the left lung and prompting mild edema on the right et tube and right subclavian line are in standard placements esophageal drainage tube passes into the stomach and out of view ct chest w o contrast impression asymmetric hyperlucency of the left lung compared to the right appears chronic and likely related to a combination of asymmetric pulmonary edema in the right lung and asymmetric emphysema in the left upper lobe superimposed bibasilar consolidations concerning for aspiration or aspiration pneumonia lipomatous hypertrophy of the intra atrial septum measuring cm is usually asymptomatic but can be associated with arrhythmias tte the left atrium is elongated the right atrium is markedly dilated there is mild symmetric left ventricular hypertrophy with normal cavity size regional left ventricular wall motion is normal left ventricular systolic function is hyperdynamic ef tissue doppler imaging suggests an increased left ventricular filling pressure pcwp 18mmhg right ventricular chamber size and free wall motion are normal the ascending aorta is mildly dilated the aortic valve leaflets are mildly thickened there is no valvular aortic stenosis the increased transaortic velocity is likely related to high cardiac output the mitral valve leaflets are mildly thickened there is no mitral valve prolapse no mitral regurgitation is seen the pulmonary artery systolic pressure could not be determined there is no pericardial effusion compared with the prior study images reviewed of left ventricular function is hyperdynamic and the heart rate is faster there is less mitral regurgitation pulmonary artery pressure is unable to be determined ruq u s w duplex impression patent hepatic vasculature mild pulsatility of the main portal vein waveform suggests underlying heart failure otherwise normal abdominal ultrasound cxr impression there has been interval removal of a right subclavian central venous catheter a right picc terminates at the lower svc a dobbhoff tube terminates within the stomach the heart size remains normal the hilar and mediastinal contours are unchanged since the prior radiograph obtained at there is no pneumothorax or focal consolidation a small left pleural effusion is unchanged brief hospital course with pmh copd on 3l home o2 dchf cad etoh abuse and schizoaffective disorder who presented with respiratory failure after recent admission at for copd exacerbation and pneumonia mixed hypoxic hypercarbic respiratory failure intubated in the ed for tachypnea in the and mixed hypoxic and hypercarbic respiratory failure this was felt secondary to copd exacerbation in the setting of discontinuing prednisone week ago for prior exacerbation this may have been exacerbated by aspiration pneumonia ct chest showed asymmetric r pulmonary edema and bibasilar infiltrates she was treated with a steroid course and initial vanc cefepime azithromycin which was narrowed to ceftriaxone azithromycin she also received lasix iv boluses to assist weaning off ventilator she was extubated on transferred to floor on on the floor she again developed respiratory distress following a likely aspiration event she was npo at the time she continued to have respiratory distress prompting a goals of care discussion during which it was felt based after discussion with her family and hcp to focus on comfort she was transitioned to comfort care on and started on a morphine drip with improvement in her respiratory distress and agitation a scopolamine patch was applied time of death was declared at on delirium patient had episodes of agitation in icu worse in evenings she has schizoaffective disorder at baseline she improved with seroquel qhs she was continued on home tetrabenazine and perphenazine svt she had episodes of svt in icu in setting of holding home metop and diltiazem this improved once home beta blockade was resumed htn home amlodipine metop and diltiazem held initially in setting of infection these were gradually re started hld continued asa pravastatin she was transitioned to comfort care on and started on a morphine drip with improvement in her respiratory distress and agitation a scopolamine patch was applied time of death was declared at on family was notified autopsy was declined discharge disposition expired discharge diagnosis copd aspiration pneumonia respiratory arrest discharge condition expired discharge instructions expired followup instructions

name unit no admission date discharge date date of birth sex m service podiatry allergies no known allergies adverse drug reactions attending chief complaint r foot osteomyelitis major surgical or invasive procedure r mpj debridement abx spacer history of present illness male patient presenting to the ed with concern for a right toe infection patient with pmh of dm with history of prior foot infections he gets his care in he states that he has a week history of a r foot hallux infection he had been on iv abx converted to orals and then started on daptomycin ertapenem by infectious disease in he relates that his foot has continued to be erythematous and swollen for the past few weeks despite abx course he was seen today by his podiatrist and had xrays take which revealed bony destruction he was then told to present to for further workup and treatment denies any recent fevers or chills no recent nausea vomiting chest pain or sob the foot is not painful but he has neuropathy past medical history dm does not recall last hgba1c htn cataracts surgery in the past social history family history n c physical exam admission phyisical exam pe vitals ra gen nad aox3 resp cta breathing comfortably on room air cv rrr abd soft nontender focused exam dp pt pulses palpable b l crt 3sec to the digits normal proximal to distal cooling edema to the r forefoot and mpj area small ulceration to the plantar aspect of the r hallux which probes deep mild erythema surrounding the r mpj no pain with palpation neuro cnii xii intact light touch sensation diminished to the b l discharge physical exam pe vitals gen nad aox3 resp cta breathing comfortably on room air cv rrr abd soft nontender focused exam crt 3sec to the digits dry surgical dressing intact pertinent results 10pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 10pm blood neuts bands lymphs monos eos baso metas myelos absneut abslymp absmono abseos absbaso 10pm blood ptt 10pm blood glucose urean creat na k cl hco3 angap 28am blood hba1c eag 34am blood crp 27pm blood lactate pm tissue proximal phalynix gram stain final no polymorphonuclear leukocytes seen no microorganisms seen tissue preliminary no growth anaerobic culture preliminary no growth pm tissue ist metatarsal gram stain final per 1000x field polymorphonuclear leukocytes no microorganisms seen tissue preliminary gram positive coccus cocci rare growth anaerobic culture preliminary no anaerobes isolated brief hospital course the patient was admitted to the podiatric surgery service from the ed on for a r foot infection on admission he was started on broad spectrum antibiotics he was taking to the or for right foot debridement on pt was evaluated by anesthesia and taken to the operating room there were no adverse events in the operating room please see the operative note for details afterwards pt was taken to the pacu in stable condition then transferred to the ward for observation post operatively the patient remained afebrile with stable vital signs pain was well controlled oral pain medication on a prn basis the patient remained stable from both a cardiovascular and pulmonary standpoint he was placed on vancomycin ciprofloxacin and flagyl while hospitalized and discharged with oral antibiotics his intake and output were closely monitored and noted to be adequate the patient received subcutaneous heparin throughout admission early and frequent ambulation were strongly encouraged the patient was subsequently discharged to home on pod3 with iv antibiotics 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 carvedilol mg po bid metformin xr glucophage xr mg po q8h amlodipine mg po daily sitagliptin mg oral daily other units bedtime insulin sc sliding scale using hum insulin aspirin mg po daily discharge medications acetaminophen mg po q6h prn pain mild daptomycin mg iv q24h duration weeks rx daptomycin mg mg iv q24h disp vial refills docusate sodium mg po bid prn constipation ertapenem sodium g iv q24h duration weeks rx ertapenem invanz gram gram iv q24h disp vial refills oxycodone immediate release mg po q4h prn pain moderate reason for prn duplicate override alternating agents for similar severity rx oxycodone mg tablet s by mouth q4 6h disp tablet refills other units bedtime insulin sc sliding scale using hum insulin amlodipine mg po daily aspirin mg po daily carvedilol mg po bid metformin xr glucophage xr mg po q8h sitagliptin mg oral daily discharge disposition home with service facility discharge diagnosis r foot osteomyelitis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions mr it was a pleasure taking care of you at you were admitted to the podiatric surgery service after your right foot surgery you were given iv antibiotics while here you are being discharged home with the following instructions activity there are restrictions on activity please remain non weight bearing to your r foot until your follow up appointment you should keep this site elevated when ever possible above the level of the heart no driving until cleared by your surgeon please call us immediately for any of the following problems redness in or drainage from your leg wound s new pain numbness or discoloration of your foot or toes watch for signs and symptoms of infection these are a fever greater than degrees chills increased redness or pus draining from the incision site if you experience any of these or bleeding at the incision site call the doctor exercise limit strenuous activity for weeks no heavy lifting greater than pounds for the next days try to keep leg elevated when able bathing showering you may shower immediately upon coming home but you must keep your dressing clean dry and intact you can use a shower bag taped around your ankle leg or hang your foot leg outside of the bathtub avoid taking a tub bath swimming or soaking in a hot tub for weeks after surgery or until cleared by your physician medications unless told otherwise you should resume taking all of the medications you were taking before surgery remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet check with your physician if you have fluid restrictions if you feel that you are constipated do not strain at the toilet you may use over the counter metamucil or milk of magnesia appetite suppression may occur this will improve with time eat small balanced meals throughout the day diet there are no special restrictions on your diet postoperatively poor appetite is not unusual for several weeks and small frequent meals may be preferred follow up appointment be sure to keep your medical appointments if a follow up appointment was not made prior to your discharge please call the office on the first working day after your discharge from the hospital to schedule a follow up visit this should be scheduled on the calendar for seven to fourteen days after discharge normal office hours are through please feel free to call the office with any other concerns or questions that might arise followup instructions

name unit no admission date discharge date date of birth sex m service neurology allergies no known allergies adverse drug reactions attending chief complaint rue pain weakness major surgical or invasive procedure none history of present illness mr is a man with afib on apixaban chf and lbbb who presents from clinic for evaluation of left hand pain and right arm pain history was obtained with help from a in yesterday he developed acute onset numbness and pain in his right hand started at 2pm when he was on the bus going home after working for a day did not do anything out of the ordinary at work did not lift heavy boxes pain numbness some tingling with needle like sensation was most severe in his right thumb and it went up his right arm gradually felt like his arm was not there and he would have to use his left hand to move his right arm around at sensation was returning and he started being able to move his arm again he took eliquis at 8pm then another at 10pm and another at midnight he felt like this helped his weakness he went to work today and noticed that he was unable to do things as quickly with his right hand he was also having some trouble with fine motor movements such as buttoning his pants still has pain in her right thumb and thenar eminence sometimes his fingertips as well pain is worse with certain positions of note he has been taking tablets of eliquis at midnight since started rather than bid past medical history afib chf lbbb varicose veins social history family history mother with cad father with liver cancer brother died of cancer physical exam admission physical examination vitals t 8f hr bp rr sao2 ra general nad heent ncat no oropharyngeal lesions neck supple irregularly irregular pulmonary breathing comfortably on ra abdomen soft nt nd extremities warm no edema neurologic examination mental status awake alert oriented x able to relate history without difficulty attentive 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 vf full to number counting eomi no nystagmus 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 ecr fex io ip quad ham ta gas l r reflexes bic tri quad gastroc l r plantar response flexor bilaterally sensory decreased sensation to pin over right thenar eminence thumb index middle ring fingers and just below the pinky finger dorsum of hand is normal as is the pinky finger decreased sensation to lt over similar areas intact elsewhere increased pain with wrist flexion and extension on the right coordination no dysmetria with finger to nose testing bilaterally able to tap each finger to thumb easily on l hand more difficult on r hand though pt says this is pain limited also slower with rapid alternating movements in r hand gait deferred discharge exam ms attentive fluent cn perrla no droop motor throughout sensory intact to light tough able to ambulate with good balance reports pain with manipulation of the first carpo metacarpal joint pertinent results 50pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 35pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 35pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 50pm blood ptt 35pm blood ptt 50pm blood glucose urean creat na k cl hco3 angap 35pm blood glucose urean creat na k cl hco3 angap 35pm blood alt ast alkphos totbili 50pm blood ck mb ctropnt 35pm blood albumin calcium phos mg cholest 35pm blood hba1c eag 35pm blood triglyc hdl chol hd ldlcalc 35pm blood tsh hand pa lat and oblique right severe osteoarthritis of the first cmc and triscaphe joint and probable mild degenerative changes of the radio scaphoid joint minimal degenerative change involving the dip joints no fracture dislocation bone erosion suspicious lytic or sclerotic lesion soft tissue calcification or radiopaque foreign body identified impression osteoarthritis including severe osteoarthritis of the first cmc and triscaphe joints no fracture or bone erosion brief hospital course man with afib on ac but not taking it correctly at the moment presents with r hand pain with a report of weakness after sleeping on the arm he has had weakness of the arm in the past after sleeping on it in a peculiar way he main complaint that brought him into the hospital is pain in the joints of the hand xray confirmed severe arthritis in the first cmc and triscaphe joint he was prescribed ibuprofen for pain and given a prescription for a wrist splint to stabilize his hand while sleeping he was also instructed to take his eliquis bid in order to best prevent future strokes he should follow up with his pcp in one week medications on admission the preadmission medication list is accurate and complete apixaban mg po bid furosemide mg po daily prn edema lisinopril mg po daily metoprolol succinate xl mg po daily simvastatin mg po qpm discharge medications ibuprofen mg po q8h prn pain moderate rx ibuprofen mg tablet s by mouth every eight hours disp tablet refills apixaban mg po bid furosemide mg po daily prn edema lisinopril mg po daily metoprolol succinate xl mg po daily simvastatin mg po qpm hand splint please provide splint to the right hand for stabilization during sleep discharge disposition home discharge diagnosis hand arthritis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr you were admitted with symptoms of hand pain we performed an xray of your hand which showed a fair amount of arthritis but no evidence of fracture or dislocation we are providing you with a prescription for ibuprofen to help with the pain as well as a hand splint to stabilize the area while you sleep it was a pleasure taking care of you neurology followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies no known allergies adverse drug reactions attending major surgical or invasive procedure cardiac catheterization no angiographically apparent cad elevated filling pressures crt d placement attach pertinent results admission labs 10am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 10am blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 22am blood ptt 10am blood glucose urean creat na k cl hco3 angap 10am blood probnp 10am blood ctropnt 00pm blood ctropnt 22am blood calcium phos mg pertinent labs 20am blood caltibc ferritn trf 20am blood tsh 00pm blood angiotensin converting microbiology 00pm blood hiv ab neg imaging cxr limited study due to low lung volumes moderate cardiac enlargement otherwise unremarkable prominent hilar contours are unchanged tte lvef dilated dyssynchronous left ventricle coronary angiography the left main left anterior descending circumflex and right coronary artery have no angiographically significant coronary abnormalities the coronary circulation is left dominant lm the left main arising from the left cusp is a large caliber vessel this vessel bifurcates into the left anterior descending and left circumflex systems lad the left anterior descending artery which arises from the lm is a large caliber vessel the diagonal arising from the proximal segment is a medium caliber vessel cx the circumflex artery which arises from the lm is a large caliber vessel the obtuse marginal arising from the proximal segment is a medium caliber vessel the atrioventricular circumflex arising from the mid segment is a medium caliber vessel the left posterior descending artery arising from the distal segment is a medium caliber vessel rca the right coronary artery arising from the right cusp is a small caliber vessel cxr there is stable elevation of the right hemidiaphragm with subsegmental atelectasis in the right lung base heart size is normal there is no pleural effusion no pneumothorax is seen no evidence of pneumonia there is stable elevation of the right hemidiaphragm with interposition of colon between the anterior abdominal wall and the liver left sided pacemaker is unchanged there is stable subsegmental atelectasis in the right lung base discharge labs 42am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 42am blood glucose urean creat na k cl hco3 angap 42am blood calcium phos mg brief hospital course transitional issues follow up with device clinic obtain repeat chem7 on to assess electrolytes on new diuretic regimen require adjustments in torsemide dose discharged on 40mg daily follow up serum ace for non ischemic dilated cardiomyopathy work up discharge weight 264lbs discharge cr code status full confirmed contact wife brief hospital summary year old male with a past medical history significant for hfpef atrial fibrillation on apixaban and htn who presented with exertional chest pain and sob only partially relieved with rest concerning for unstable angina on admission troponins peaked at a mild elevation of ekg was without any ischemic changes patient was initially on a nitro gtt which was discontinued upon resolution of cp patient underwent coronary angiography on which revealed no apparent cad but did reveal elevated filling pressures tte on this admission revealed newly reduced ef of with a dilated and dyssynchronous lv patient underwent inpatient crt d placement he was further diuresed with iv lasix boluses before transitioning to torsemide 40mg daily course complicated by short 6sec episodes of nsvt for which he was uptitrated on his nodal blocker but continues to have intermittent palpitations upon discharge coronaries no obstructive cad pump lvef rhythm af active issues ua nstemi patient initially presented after experiencing l anterior chest pressure discomfort that was provoked by exertion and only partially relieved with rest patient states that over the past several months he has had similar pains although less severe he notes they only occur with physical exertion or with emotion duress associated with this pain he found himself sob and diaphoretic on admission he was noted to have a mild troponin elevation which peaked at ekg was without ischemic changes patient was managed on a heparin gtt as well as daily aspirin and statin for concern for acs patient was initially on a beta blocker however on this was held as patient was notably bradycardic overnight to albeit while asleep and otherwise asymptomatic patient underwent coronary angiography on which revealed no apparent cad but elevated filling pressures hfpef hfref patient with a history of non ischemic cardiomyopathy and associated hfpef of unclear etiology suspected htn heart disease throughout admission patient appeared euvolemic and not otherwise decompensated he exhibited some mild trace edema over the rle but he notes this is chronic and related to venous insufficiency patient did not have an elevated bnp on admission on patient underwent repeat tte as he had none prior since repeat tte revealed newly reduced lvef of as well as dilated lv and underlying dssynchrony ep was consulted and patient underwent crt d placement workup for non ischemic cardiomyopathy including tsh hiv and iron panel ace level pending as above patient was subsequently actively diuresed with iv boluses of lasix before transitioning to torsemide 40mg daily crt d placement on patient was started back on metoprolol titrated to 150mg daily he is unable to life heavy objects for weeks in setting of crt d through will write work note to excuse from heavy duties at discharge atrial fibrillation patient on metoprolol and apixaban at home apixaban was held initially during his hospitalization while on heparin gtt as above his apixaban was restarted following cath his metoprolol was initially held secondary to significant albeit asymptomatic bradycardia to while asleep crt d placement metoprolol was restarted and increased as above to attempt to address intermittent nsvt chronic issues osa continued home cpap htn continued his home lisinopril metoprolol was held for reasons stated above and was continued upon discharge minutes spent at patient s bedside coordination of care discharge planning medications on admission the preadmission medication list is accurate and complete apixaban mg po bid lisinopril mg po daily metoprolol succinate xl mg po daily simvastatin mg po qpm discharge medications atorvastatin mg po qpm metoprolol succinate xl mg po daily nitroglycerin sl mg sl q5min prn chest pain torsemide mg po daily apixaban mg po bid lisinopril mg po daily discharge disposition home discharge diagnosis primary diagnoses atypical chest pain hfref non ischemic dilated cardiomyopathy crt d secondary diagnoses atrial fibrillation osa htn non sustained ventricular tachycardia 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 at the why was i in the hospital were admitted because had chest pain and shortness of breath what happened in the hospital received medications which helped your chest pain underwent cardiac catheterization a procedure that allowed us to visualize the arteries of your heart this procedure revealed no blockages in your heart but did show the pressures in your heart were high were treated with diuretic medications to lower the pressure in your heart received crt d a pace making device that may help your heart function better what should i do when i go home be sure to take all your medications and attend all of your appointments listed below your weight at discharge is 264lbs please weigh yourself today at home and use this as your new baseline please weigh yourself every day in the morning call your doctor if your weight goes up by more than lbs thank for allowing us to be involved in your care we wish all the best your healthcare team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies shellfish derived attending chief complaint ams major surgical or invasive procedure none history of present illness hx uncontrolled dm2 c b small vessel cva vascular dementia recent l5 nerve root injection frequent uti p w one week ams and nonfocal weakness superimposed on months of chronic behavior changes history obtained from daughter long term care as patient unable to remember recent history at baseline pt gives conflicting answers and has very poor short term memory however over the last week she is more confused talking to herself and seems to be hallucinating crying inappropriately hard time mobilizing to car weakness crying in a wheelchair lost her hope she couldn t walk at all she usually only uses a wheelchair for longer trips outside the house and uses the rolling walker in the house night she could not hold herself at all not even to transfer from wheelchair to bed since she hasn t been able to go to day care not able to bathe in tub patient was treated with cipro for uti however abx stopped after the cultures were negative has had months of intermittent urinary incontinence daughter has not noted any new breathing symptoms has a chronic dry cough no sputum production has chronic intermittent constipation intermittent enemas at home no fevers no chills no clear sweats maybe that one day it was very hot no n v d h o small vessel cva vascular dementia at baseline attends adult day care 4x week uses rolling walker for ambulation mini mental behavior changes noted in outpt notes pt has had at least falls since fall with head trauma and presented to bid ed where showed no acute intracranial process chronic small vessel disease and old lacunar infarcts unchanged from prior in the ed initial vitals ra labs were significant for plt alb cxr ed volumes are low with bibasal opacities most suggestive of atelectasis though difficult to exclude a component of pneumonia in the correct clinical setting ekg ed in the ed pt received iv ceftriaxone 1g iv azithromycin 500mg vitals prior to transfer ra currently patient is laying comfortably in bed afebrile ros no photophobia no fevers chills ha changes in vision abd pain burning on urination dyspnea past medical history vascular dementia without behavioral disturbance stroke small vessel around she was noted to have problems with speaking forgetfulness and mild right sided weakness she was seen at for an mri scan on which showed diffuse periventricular white matter disease there was also a subacute hemorrhagic infarct in the left lobe of the globus palates and the genu of the internal capsule mr angiography of the and neck were normal lumbar radiculitis sx include low back and r leg pain since mri lumbar spine showed severe l4 l5 circumferential disc bulge with right neural foraminal stenosis s p r l5 lumbar transforaminal selective nerve root injection cc of kenalog mg ml and cc of of lidocaine on dm diabetes mellitus type uncontrolled w neurologic complication cva retinopathy mild nonproliferative diabetic retinopathy nephrotic syndrome ckd stage g2 a3 gfr and albumin creatinine ratio mg g minimal change disease hypothyroidism atrophic thyroid on us prob s hypertension essential hypercholesterolemia ldl goal social history family history mother had dm2 lived to no family hx of dementia physical exam admission physical vs ra gen alert lying in bed no acute distress unable to sit up without assistance apparently due to truncal weakness heent moist mm anicteric sclerae no conjunctival pallor neck supple pulm bibasilar crackles no wheezes cor rrr s1 s2 no m r g abd soft non tender non distended no lower abdominal ttp extrem warm well perfused no edema dp b l neuro a ox2 symmetric smile grimace shoulder shrug head turn mild l ptosis neg pronator drift b l strength rue limited by r shoulder pain strength lue strength b l discharge physical vitals ra general alert laying in bed no acute distress heent mmm anicteric sclera lungs clear to auscultation bilaterally no wheezes cv regular rate and rhythm normal s1 s2 no murmurs abdomen soft non distended ext warm well perfused no clubbing cyanosis or edema neuro does not cooperate fully with neuro exam oriented to self and hospital does not know year mild l ptosis b l stiffness on passive plantarflexion and dorsiflexion stiff cogwheeling at wrists b l pertinent results admission labs 53pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 53pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 53pm blood glucose urean creat na k cl hco3 angap 53pm blood alt ast alkphos totbili 20am blood ck cpk 53pm blood ctropnt 20am blood ck mb ctropnt 53pm blood albumin calcium 20am blood calcium phos mg 20am blood tsh 20am blood free t4 24am blood lactate 53pm blood lipase discharge labs 20am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 20am blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 20am blood glucose urean creat na k cl hco3 angap 20am blood calcium phos mg micro am blood culture final report blood culture routine final no growth am blood culture final report blood culture routine final no growth pm urine source catheter final report urine culture final no growth imaging summaries imaging mri cervical thoracic lumbar lumbar spondylosis similar from examination of with degenerative grade anterolisthesis of l4 on l5 and l5 on s1 severe l4 l5 spinal canal narrowing crowding the cauda equina severe l4 l5 right and moderate to severe neural foraminal narrowing and bilateral l5 s1 moderate to severe bilateral neural foraminal narrowing cervical spondylosis results in bilateral moderate neural foraminal narrowing at multiple levels without high grade spinal canal narrowing no significant spinal canal or neural foraminal narrowing at the thoracic spine no cord signal abnormality additional findings as described above imaging mr head w o contrast no acute infarct confluent moderate to severe subcortical and periventricular t2 flair white matter hyperintensities are nonspecific but compatible with chronic microangiopathy in a patient of this age moderate cerebral volume loss additional findings as described above imaging ct head w o contrast no intracranial hemorrhage stable chronic lacunar infarct left basal ganglia internal capsule severe chronic small vessel ischemic changes imaging chest pa lat ap upright and lateral views of the chest provided lung volumes are low with bibasal opacities most suggestive of atelectasis though difficult to exclude a component of pneumonia in the correct clinical setting no large effusion pneumothorax no signs of congestion or edema cardiomediastinal silhouette is unchanged bony structures appear intact bd pelvis with co no acute findings to account for abdominal pain incidental findings as detailed above brief hospital course ms is a with poorly controlled dm2 c b small vessel cva and vascular dementia who presents with one week of worse than usual confusion increased frequency of urinary incontinence and nonfocal weakness superimposed on months of chronic behavior changes likely progression of vascular dementia she was noted to have intermittent urinary retention while admitted acute issues altered mental status believed to be progression of vascular dementia ich ischemic stroke ruled out by nchct and mri patient is afebrile no leukocytosis neg ucx from cxr shows most likely atelectasis and no sob change in chronic dry cough no current medications or electrolyte abnormalities that could cause toxic metabolic ams nph unlikely given imaging neuro consulted recommended contrast mri of brain and c t l spine these spine mris showed no interval changes compared to prior in stable lumbar and cervical spondylosis with spinal canal narrowing and neural foramen narrowing mri brain shows no acute infarct just confluent subcortical changes c w chronic microangiopathy ortho spine does not think surgery is indicated in this pt because her neuro deficits do not correlate with mri findings so surgery not likely to improve her function per neuro movement disorders pt has parkinsonism from either vascular dementia vs actual dz plan is to trial carbidopa levodopa tab po tid until follow up with dr in months urinary incontinence subacute vs chronic could be related to progression vascular dementia bladder scans this admission c f retention decided on straight cath bid with titration of frequency as needed chronic issues nephrotic syndrome high protein diet ensure chronic last albumin also in outpatient setting in monitor albumin urine protein and albumin htn continue home losartan 100mg po qd and hydrochlorothiazide25mg po qd dm2 managed with lifestyle interventions at home started iss because hypothyroidism continue home levothyroxine mcg po qd hypercholesterolemia continue home simvastatin mg tablet po qpm transitional issues re check tsh in weeks as outpt was here with normal free t4 family education on physical assist straight cathing some of daughters are bid straight catherization tirate frequency as needed submitted requet for electric bed will also need lift and ramp at home before returning home medications on admission the preadmission medication list is accurate and complete levothyroxine sodium mcg po daily losartan hydrochlorothiazide mg oral daily simvastatin mg po qpm docusate sodium mg po bid artificial tears drop both eyes tid melatonin mg oral qpm prn aspirin mg po daily acetaminophen mg po bid prn pain mild fluticasone propionate nasal spry nu daily discharge medications carbidopa levodopa tab po tid polyethylene glycol g po daily prn constipation senna mg po bid prn constipation acetaminophen mg po q8h prn pain mild artificial tears drop both eyes tid aspirin mg po daily docusate sodium mg po bid fluticasone propionate nasal spry nu daily levothyroxine sodium mcg po daily losartan hydrochlorothiazide mg oral daily melatonin mg oral qpm prn simvastatin mg po qpm discharge disposition extended care facility discharge diagnosis weakness acute on chronic encephalopathy or dementia urinary incontinence and urinary retention discharge condition mental status confused always level of consciousness alert and interactive activity status out of bed with assistance to chair or wheelchair discharge instructions dear and family why was i admitted to the hospital you have been more confused over the past week you have been having weakness as well what was done for me in the hospital we ruled out other causes of your confusion and believe it is due to progression of your vascular dementia a head ct and brain mri were performed our neurologist and movement disorder specialists evaluated you for your weakness and rigidity and started you on sinemet for stiffness we worked with case management to apply for more equipment at home for after rehab what should i do when i go back to home review your medication list and take as prescribed follow up with the neurology movement disorder clinic as recommended below work with your rehab doctors please work with physical therapy straight cath twice a day and record the values of how much urine comes out in a log to show your doctor it was a pleasure to take part in your care sincerely your team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies shellfish derived attending chief complaint cough fever lethargy major surgical or invasive procedure none history of present illness y o woman with history of uncontrolled type dm complicated by small vessel cva vascular dementia recent l5 nerve root injection and frequent uti presenting with several days of cough and fever to patient s family who she lives with have noticed that patient has had progressive cough and general weakness over the last several days they state that she is usually able to eat meals and walk to the bathroom independently but that she was unable to do so yesterday and has just generally been weaker and slower in movement she endorses mild shortness of breath but denies any chest pain headaches lightheadedness fainting abdominal pain changes in bowel movement or urination she has recently had multiple sick contacts at home with runny nose and cough in the ed initial vital signs were notable for t99 hr92 bp118 rr18 ra exam notable for coarse crackles on the right side labs were notable for wbc hgb plt agap lactate vbg fluapcr negative flubpcr negative ua notable for protein glucose no nitrites ketones or leuks studies performed include nchct no intracranial hemorrhage new hypodensities in the right thalamus and internal capsule are age indeterminate and subacute infarction not excluded mri could be performed for further assessment stable chronic lacunar infarcts in the left basal ganglia and internal capsule cxr heart size is mildly enlarged unchanged the mediastinal and hilar contours are similar to prior the pulmonary vasculature is not engorged lung volumes are low with minimal patchy opacities at the lung bases no focal consolidation pleural effusion or pneumothorax is seen there are no acute osseous abnormalities impression low lung volumes with patchy opacities at the lung bases likely reflective of atelectasis infection however is difficult to exclude in the appropriate clinical context patient was given 43ivceftriaxone 37ivazithromycin 500mg 02ivfns ml 09scinsulin units 52ivacetaminophen iv mg 30po ngcarbidopa levodopa tab 30po nglevothyroxine sodium mcg consults none vitals on transfer t98 hr76 bp123 rr20 ra upon arrival to the floor patient states that she presented to the hospital yesterday due to difficulty walking and her daughter describes that she is normally able to ambulate independently with a walker she endorses a cough over the last several days which her daughter states is productive and has been worsening today she denies headache chills shortness of breath chest pain abdominal pain diarrhea constipation dizziness or pain with urination she is intermittently somnolent patient has received an influenza vaccine and pneumonia vaccine this year patient s last hospitalization was years ago for neurological symptoms of memory speech and gait difficulty collateral from daughter patient had a cough weeks ago which improved and was nearly resolved however two nights ago patient began to have a wet cough though without sputum and began to make crying noises throughout the night yesterday the patient began to have trouble walking she normally ambulates with a walker independently but yesterday she was unable to do so and was dragging her right leg her daughter took her temperature which showed a fever of patient was also unable to eat independently yesterday as well which is different from her baseline she had chills and shortness of breath yesterday but did not have headache dizziness lightheadedness diarrhea changes in sensation or burning with urination past medical history vascular dementia without behavioral disturbance vascular parkinsonism stroke small vessel diffuse periventricular white matter disease there was also a subacute hemorrhagic infarct in the left lobe of the globus palates and the genu of the internal capsule lumbar radiculitis dm diabetes mellitus type uncontrolled w neurologic complication cva retinopathy mild nonproliferative diabetic retinopathy nephrotic syndrome ckd stage g2 a3 gfr and albumin creatinine ratio mg g minimal change disease hypothyroidism hypertension essential hypercholesterolemia depressed affect thrombophlebitis phlebitis of deep veins gout pvd posterior vitreous detachment social history history mother had dm2 lived to no family hx of dementia physical exam admission physical exam vitals temp po bp hr rr o2 sat o2 delivery ra general somnolent in no acute distress heent ncat perrl eomi sclera anicteric and without injection mmm neck no cervical lymphadenopathy no jvd cardiac regular rhythm normal rate audible s1 and s2 no murmurs rubs gallops lungs crackles in the base of the right lung no increased work of breathing back no spinous process tenderness no cva tenderness abdomen normal bowel sounds non distended non tender to deep palpation in all four quadrants no organomegaly extremities no clubbing cyanosis or edema pulses dp radial bilaterally skin warm cap refill 2s no rash neurologic cn2 intact strength throughout upper extremities left lower extremity strength in right lower extremity normal sensation gait deferred states initially that she is in s unable to name the year mild bradykinesia mild cogwheeling discharge physical exam temp po bp r lying hr rr o2 sat o2 delivery ra general lying in bed covered in many blankets drowsy cardiac regular rate and rhythm ii vi systolic crescendo decrescendo murmur at the right upper sternal border lung breathing comfortably on room air bibasilar crackles abd abdomen soft nontender nondistended ext warm well perfused no lower extremity edema neuro awake is able to state her name location but not the date she follows commands squeezes hands lifts legs overall mental status appears improved from yesterday pertinent results admission labs 26pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 26pm blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 26pm blood plt 26pm blood glucose urean creat na k cl hco3 angap 31pm blood po2 pco2 ph caltco2 base xs 39pm blood po2 pco2 ph caltco2 base xs 31pm blood glucose lactate k 11am urine color straw appear hazy sp 11am urine blood neg nitrite neg protein glucose ketone neg bilirub neg urobiln neg ph leuks neg 11am urine rbc wbc bacteri none yeast none epi discharge labs 47am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 47am blood plt 47am blood glucose urean creat na k cl hco3 angap 47am blood calcium phos mg 00am blood hba1c eag micro am urine final report urine culture final no growth pm urine source legionella urinary antigen final negative for legionella serogroup antigen reference range negative imaging reports cxr impression low lung volumes with patchy opacities at the lung bases likely reflective of atelectasis infection however is difficult to exclude in the appropriate clinical context non con head ct impression study is degraded by motion no evidence of acute intracranial hemorrhage age indeterminate right thalamus and internal capsule lesions as described not definitely seen on most recent prior imaging of while findings may represent microangiopathic changes subacute infarction is not excluded on the basis examination please note mri of the brain is more sensitive for the detection of acute infarct stable chronic lacunar infarcts in the left basal ganglia and internal capsule atrophy probable small vessel ischemic changes and atherosclerotic vascular disease as described mri brain without contrast impression the study significantly degraded by patient motion allowing for this limitation there is no evidence large intracranial hemorrhage obvious infarction or intracranial mass nonspecific confluent white matter changes in the cerebral hemispheres bilaterally likely sequela of chronic small vessel ischemic changes old lacunar infarcts in the left basal ganglia region cxr impression patchy opacities in the left lower lobe could reflect atelectasis aspiration or pneumonia non con head ct impression no acute intracranial process chest cta impression no evidence of pulmonary embolism or acute aortic abnormality circumflex aorta noted resulting in vascular sling which potentially could be contributing to patient s aspiration left greater than right lower lobe airspace disease compatible with pneumonia may be secondary to aspiration given the fluid seen within the proximal esophagus mildly prominent hilar lymph nodes which are likely reactive brief hospital course y o woman with history of uncontrolled type dm complicated by small vessel cva vascular dementia recent l5 nerve root injection and frequent utis presented with several days of cough fever to found to have pneumonia on cxr course was complicated by increased somnolence likely secondary to infection and concerns about new r sided leg weakness but stable mri and clinical improvement in strength by discharge acute issues aspiration pneumonia patient s symptoms crackles in the right lung base and cxr demonstrative of patchy opacities in the lung bases c f pneumonia empiric treatment for community acquired pneumonia with ceftriaxone and azithromycin was initiated without significant improvement despite cap therapy patient continued to have mildly elevated temperatures tmax concerning for inadequate source control patient did not demonstrate any symptoms and signs of other infections such as uti negative ua ucx skin clean skin around pivs no new rashes or cns infection no headache blurry vision no evidence of inflammation on mri aspiration pneumonia was a possible cause of the patient s lack of improvement given patient s hx of stroke dysarthria recent difficulty with feeding herself independently and aspiration risk determined by speech therapy flagyl was added for coverage of anaerobic organisms in aspiration pneumonia patient triggered due to tachypnea overnight for likely aspiration event pe was ruled out antibiotics were switched to augmentin on in order to consolidate multiple antibiotics she will complete augmentin on for a day course for aspiration pneumonia on the day of discharge she was evaluated again by speech and swallow and was recommended to stay on a pureed diet and have further evaluation in rehab somnolence patient has waxing and waning alertness and is somnolent head ct and mri negative for acute bleed or stroke vbg without evidence of co2 retention labs without significant electrolyte abnormalities her mental status improved as her infection was treated however she still remained intermittently confused this appears to be consistent with her baseline per family gait instability new findings on acute onset of gait instability on different from her baseline patient has a significant history of vascular dementia with multiple prior infarcts demonstrated hypodensities in the right thalamus and internal capsule concerning for subacute infarcts however mri did not show any new lesions patient s gait instability may be re crudescence of neurological symptoms from prior strokes in the acute setting of infection chronic issues vascular dementia parkinsonism patient sees outpatient neurologist at and is taking carbidopa levodopa and donepezil we continued her carbidopa mg levodopa mg tablets po tid donepezil mg tablet po qhs aspirin and statin dm type patient with poorly controlled t2dm her pcp has been following this last a1c was about in now increased further to his plan was to continue lifestyle modification unless her fasting glucose reached at which point he planned to start metformin while she was in the hospital she required about units insulin sliding scale daily we discharged her with plan to start metformin for better diabetes control nephrotic syndrome ckd stage g2 a3 minimal change disease home losartan hctz was initially held in setting of normotension but were restarted on hypothyroidism continued home levothyroxine mcg capsule daily essential hypertension see above re losartan hctz hypercholesterolemia we continued her home simvastatin mg tablet daily depressed affect appetite we continued her home mirtazapine mg disintegrating tablet daily qhs transitional issues new medication metformin start metformin mg bid and titrate adjust as appropriate a1c is new medication augmentin continue augmentin mg bid for aspiration pneumonia until maintain pureed solids and nectar thick liquids for aspiration risk continue speech and swallow evaluations while in rehab code full code contact daughter hcp work medications on admission the preadmission medication list is accurate and complete losartan hydrochlorothiazide mg oral daily carbidopa levodopa tab po tid simvastatin mg po qpm levothyroxine sodium mcg po daily mirtazapine mg po qhs donepezil mg po qhs senna mg po qhs docusate sodium mg po daily psyllium wafer waf po daily multivitamins tab po daily artificial tears drop both eyes tid aspirin mg po daily acetaminophen mg po bid prn pain mild fever discharge medications amoxicillin clavulanic acid mg po q12h duration days metformin glucophage mg po bid acetaminophen mg po bid prn pain mild fever artificial tears drop both eyes tid aspirin mg po daily carbidopa levodopa tab po tid docusate sodium mg po daily donepezil mg po qhs levothyroxine sodium mcg po daily losartan hydrochlorothiazide mg oral daily mirtazapine mg po qhs multivitamins tab po daily psyllium wafer waf po daily senna mg po qhs simvastatin mg po qpm discharge disposition extended care facility discharge diagnosis primary diagnoses aspiration pneumonia oropharyngeal dysphagia secondary diagnoses vascular dementia discharge condition mental status confused sometimes level of consciousness alert and interactive activity status out of bed with assistance to chair or wheelchair discharge instructions dear ms it was a pleasure taking care of you at the why did you come to the hospital you came into the hospital because you were having cough and your family was worried about your walking what did you receive in the hospital while you were in the hospital we did some imaging studies to make sure you had not had another stroke or a clot in your lungs we treated you with antibiotics for pneumonia you were seen by our speech swallow specialists who were concerned that food may be going into your lungs when you eat what should you do once you leave the hospital you should continue to take all your medications as prescribed and follow up with your medical appointments we wish you all the best sincerely your care team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies shellfish derived attending major surgical or invasive procedure none attach pertinent results laboratory results 30pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 45am 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 glucose urean creat na k cl hco3 angap 45am blood glucose urean creat na k cl hco3 angap 30pm blood alt ast alkphos totbili 30pm blood albumin 32am blood lactate urine culture urine culture final escherichia coli cfu ml presumptive identification cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h sensitivities mic expressed in mcg ml escherichia coli ampicillin s ampicillin sulbactam s cefazolin s cefepime s ceftazidime s ceftriaxone s ciprofloxacin s gentamicin s meropenem s nitrofurantoin s piperacillin tazo s tobramycin s trimethoprim sulfa s brief hospital course on admission ms was started empirically on cefepime to cover her previously resistant organisms this was narrowed to oral ciprofloxacin after culture results revealed pan sensitive e coli her kidney injury resolved and her mental status returned to her baseline as she was at her physical baseline she was discharged back to her home with home services hospital course by problem e coli uti cipro mg bid x additional days resolved completely t2dm metformin htn losartan hctz home history of cva aspirin and simvastatin vascular dementia continue home donepezil history of dvt continue home apixaban hypothyroidism home levothyroxine minutes spent on discharge activities patient examined on day of discharge medications on admission the preadmission medication list is accurate and complete acetaminophen mg po bid prn pain mild fever artificial tears drop both eyes tid aspirin mg po daily carbidopa levodopa tab po tid donepezil mg po qhs levothyroxine sodium mcg po daily mirtazapine mg po qhs multivitamins tab po daily senna mg po daily simvastatin mg po qpm docusate sodium mg po daily losartan hydrochlorothiazide mg oral daily psyllium wafer waf po daily metformin glucophage mg po bid discharge medications ciprofloxacin hcl mg po q12h rx ciprofloxacin hcl mg tablet s by mouth twice a day disp tablet refills acetaminophen mg po bid prn pain mild fever artificial tears drop both eyes tid aspirin mg po daily carbidopa levodopa tab po tid docusate sodium mg po daily donepezil mg po qhs levothyroxine sodium mcg po daily losartan hydrochlorothiazide mg oral daily metformin glucophage mg po bid mirtazapine mg po qhs multivitamins tab po daily psyllium wafer waf po daily senna mg po daily simvastatin mg po qpm discharge disposition home with service discharge diagnosis e coli uti discharge condition activity status ambulatory requires assistance or aid walker or cane level of consciousness alert and interactive mental status confused always discharge instructions you were admitted to the hospital with a urinary tract infection you were started on antibiotics and rapidly improved fortunately your organism was sensitive to oral antibiotics you will complete three additional days of ciprofloxacin followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies atenolol amlodipine tekturna felodipine lisinopril diovan attending chief complaint chest pain l shoulder pain major surgical or invasive procedure none history of present illness w pmhx cad s p stemi w pci to mid lad htn previous hx of diverticulitis and ckd stage ii presenting with chest l shoulder pain patient was in her usoh until over about the last week she noticed pain in her l shoulder which wrapped around into her l rib cage she noted this pain first after raking some leaves in her yard and notes that she continued to have some symptoms at night if she slept on that shoulder noted that the pain improved with tylenol and with topical mineral oil she then woke up this morning and reports developing substernal chest discomfort that was constant for about an hour but resolved without intervention she also experienced some sob but denied diaphoresis or palpitations patient noted the pain is quite different than what she experienced during her mi which she described as an on her chest past medical history cad stemi s p occlusion htn dmii diet controlled ckd stage ii started after appendicitis and bacteremia in obesity impingement syndrome left shoulder gerd hld tia social history family history htn in mother cva and prostate cancer in father physical exam admission pe vitals ra general pleasant f in nad heent ncat mmm cv rrr no m r g lungs ctab abdomen soft nt nd bs ext wwp no c c e skin warm dry no rashes or notable lesions neuro aaox3 grossly intact discharge pe vs temp po bp hr o2 sat today s weight kg lb tele sb no ectopy general pleasant in nad heent ncat mmm cv rrr no m r g lungs ctab abdomen soft nt nd bs ext wwp no c c e skin warm dry no rashes or notable lesions neuro aaox3 grossly intact pertinent results admission labs 45pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 45pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 45pm blood ptt 45pm blood glucose urean creat na k cl hco3 angap 45pm blood alt ast alkphos totbili 45pm blood ctropnt 21pm blood ctropnt 45pm blood albumin chest pa lat findings pa and lateral views of the chest provided lungs are clear there is no focal consolidation effusion or pneumothorax there are no signs of congestion or edema the cardiomediastinal silhouette is normal imaged osseous structures are intact no free air below the right hemidiaphragm is seen impression no acute intrathoracic process discharge labs 45am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 45am blood ptt 45am blood glucose urean creat na k cl hco3 angap 45am blood calcium phos mg ssessment plan w pmhx cad s p stemi w pci to mid lad htn previous hx of diverticulitis and ckd stage ii presented with chest l shoulder pain coronaries occlusion mid lad s p pci pump lvef rhythm sinus brady cad s p stemi w pci to mid lad chest pain patient presented with one day history of substernal cp which resolved prior to admission reassuringly w o ischemic changes to ecg and trop negative x2 has a history of stemi in s p pci to mid lad initially c o shoulder pain which seems to be much more msk and entirely different than the substernal discomfort and dyspnea which prompted her to be evaluated in the ed pt would like to go home and do stress test as outpatient continue asa 81mg continue ticagralor 90mg bid continue atorva mg daily continue carvedilol mg bid nuclear stress test ordered to be done as outpt possibly tomorrow htn continue carvedilol hctz gerd continue pantoprazole ckd stage ii at baseline appears to be around creat today dispo discharge home today with plans to have outpatient nuclear stress test in days follow up with dr next week pt will call for appointment transitional none medications on admission the preadmission medication list is accurate and complete aspirin mg po daily latanoprost ophth soln drop both eyes qhs pantoprazole mg po q12h atorvastatin mg po qpm ticagrelor mg po bid to prevent stent thrombosis vitamin d unit po daily carvedilol mg po bid hydrochlorothiazide mg po daily oxybutynin xl nf mg other daily discharge medications aspirin mg po daily atorvastatin mg po qpm carvedilol mg po bid hydrochlorothiazide mg po daily latanoprost ophth soln drop both eyes qhs oxybutynin xl nf mg other daily pantoprazole mg po q12h ticagrelor mg po bid to prevent stent thrombosis vitamin d unit po daily discharge disposition home discharge diagnosis angina pectoris cad htn discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted with left shoulder and left sided chest pain lab work and ekg did not show that you were having a heart attack however we would like to do a stress test on you in days with your heart attack history last please call the number that was provided to you and schedule the test possibly tomorrow please call dr tomorrow and make an appointment to see him early next week so dr go over the stress results with you continue all of your medications without any changes if you have any urgent questions that are related to your recovery from your medical issues or are experiencing any symptoms that are concerning to you and you think you may need to return to the hospital please call the heartline at to speak to a cardiologist or cardiac nurse practitioner it has been a pleasure to have participated in your care and we wish you the best with your health your cardiac care team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies atenolol amlodipine tekturna felodipine attending chief complaint headache chest pain abdominal pain major surgical or invasive procedure none history of present illness female with history of hypertension hyperlipidemia and metabolic syndrome on metformin presenting with headache chest pain and abdominal pain patient reports since she has had a few days of left sided abdominal pain and gradual onset of headache she reported associated chills and generalized weakness reports today she had an episode of vomiting therefore presented for evaluation patient also reports few days of intermittent chest pain it started on she says she experiences chest pain occasionally and this feels very similar reports chest pain with radiation into the left side or the right side intermittently nonexertional without obvious triggers states she burps a lot when she rubs her chest mostly chest pain comes when lying down no relation to food no alleviating or exacerbating factor associated shortness of breath denies diaphoresis lightheadedness denies fever diarrhea melena hematochezia dysuria hematuria denies leg pain leg swelling history dvt pe in regards to left lower quadrant pain began a few days prior and has prior history of diverticulitis and this feels similar she endorses constipation had associated chills no recorded fevers vomiting x1 today pain not radiating to back in regards to headache it started with a gradual onset headache which is similar to her prior tension type headaches which she gets occasionally by character and severity onset and early afternoon maximal by evening this is been waxing and waning since then dull dominantly frontal no radiation or paresthesias no vertigo no lightheadedness past medical history ckd stage ii started after appendicitis and bacteremia in htn metabolic syndrome obesity impingement syndrome left shoulder gerd hld tia social history family history fh htn in mother cva and prostate cancer in father physical admission physical exam vs ra general nad heent at nc eomi perrl anicteric sclera pink conjunctiva mmm neck supple no lad no jvd heart rrr s1 s2 no murmurs gallops or rubs lungs ctab no wheezes rales rhonchi breathing comfortably without use of accessory muscles abdomen nondistended tender to palpation in left lower quadrant 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 vs 9po ra general nad laying back in bed heent at nc eomi no jvd no lad neck supple cardiac rrr s1 s2 normal no m g r appreciated pulm ctab abd bs non distended tender to deep palpation of left side particularly in the llq no organomegaly no guarding ext pulses present no edema neuro no motor sensory deficits elicited pertinent results admission labs 50pm ctropnt 45pm urine color yellow appear clear sp 45pm urine blood tr nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn ph leuk neg 45pm urine bacteria few yeast none 35pm glucose urea n creat sodium potassium chloride total co2 anion gap 35pm estgfr using this 35pm alt sgpt ast sgot alk phos tot bili 35pm lipase 35pm ctropnt 35pm albumin 35pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 35pm neuts monos eos basos im absneut abslymp absmono abseos absbaso 35pm plt count 35pm ptt discharge labs 05am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 05am blood plt 05am blood glucose urean creat na k cl hco3 angap 05am blood alt ast alkphos totbili 05am blood calcium phos mg imaging ct a p w contrast moderate wall thickening and fat stranding surrounding a few descending colonic diverticulum compatible with acute uncomplicated diverticulitis specifically there are no focal fluid collections or evidence of pneumoperitoneum hyperdensity within the wall of the right colonic diverticula which is new compared to prior and may represent ingested material or mucosal hyperemia in addition there are few prominent mesenteric lymph nodes within the right hemiabdomen which have increased in size compared to prior examinations these findings should be followed up with ct in months mm ground glass nodule within the right middle lobe unchanged since fibroid uterus mild anterolisthesis of l5 on s1 due to bilateral pars defects cxr no evidence of pneumonia micro urine cx pnd blood cx x2 pnd brief hospital course ms is a w metabolic syndrome previous diverticulitis tension headaches and ckd stage ii who presents with left lower quadrant pain chest pain and headache for the last week found to have uncomplicated diverticulitis on imaging acute issues diverticulitis patient has had gradual onset of left lower abdominal pain which is similar to previous bouts of diverticulitis imaging was notable for uncomplicated diverticulitis patient did not have leukocytosis or fever and there was not current concern for complicated diverticulitis based on imaging was started on ciprofloxacin and metronidazole in addition to ivf her symptoms improved and she tolerated a regular diet so was discharged with plans for pcp chest pain in the ed there was initially concern for cardiac chest pain but upon further review with the patient she has had the same intermittent chest pain for several years which has been unchanged the pain lacked characteristics suggestive of cardiac ischemia her ekg was unchanged from prior troponins were negative and her prior cardiac work up for the same symptoms has been negative therefore further diagnostics were not pursued at this time she had no chest pain after the time of admission her chest pain seemed most consistent with a gi cause such gerd given the report of improving with burping headache currently resolved patient states that this is reminiscent of previous tension type headaches which may have been exacerbated by dehydration in setting of vomiting diverticulitis received tylenol prn ct finding requiring hyperdensity within the wall of the right colonic diverticula which is new compared to prior and may represent ingested material or mucosal hyperemia in addition there are few prominent mesenteric lymph nodes within the right hemiabdomen which have increased in size compared to prior examinations these findings should be followed up with ct in months or colonoscopy for the right colonic lesion transitional issues new medications metronidazole mg po ng q8h ciprofloxacin mg po q12h colonoscopy should be performed except if she had colonoscopy within the previous year chest pain workup had a negative stress test years ago and presentation much more likely consistent w gerd was told to sit upright after eating and eat foods that do not cause her reflux symptoms complete day course of cipro flagyl until ct in months as per above code full presumed contact medications on admission the preadmission medication list is accurate and complete diltiazem extended release mg po daily latanoprost ophth soln drop both eyes qhs metformin glucophage mg po daily pantoprazole mg po q12h rosuvastatin calcium mg po qpm aspirin ec mg po daily vitamin d unit po daily melatonin unknown mg oral daily fish oil omega mg po daily central vite womens mature multivit min iron fa lutein mg iron mcg mcg oral daily 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 aspirin ec mg po daily central vite womens mature multivit min iron fa lutein mg iron mcg mcg oral daily diltiazem extended release mg po daily fish oil omega mg po daily latanoprost ophth soln drop both eyes qhs melatonin unknown oral daily metformin glucophage mg po daily pantoprazole mg po q12h rosuvastatin calcium mg po qpm vitamin d unit po daily discharge disposition home discharge diagnosis primary diverticulitis chest pain secondary gastroesophageal reflux disease diabetes mellitus type ii hypertension hyperlipidemia 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 why was i in the hospital you were hospitalized because you had abdominal pain and were found to have a recurrent episode of your diverticulitis which is an infection in a part of your large intestines what was done while i was in the hospital pictures were taken that showed you had an infection and inflammation in a part of your large intestines which you ve experienced before pictures were taken of your heart which did not show any concerning changes you also had blood tests which showed that your heart was not experiencing any sudden injury you were started on medications called antibiotics to treat this infection in your intestines what should i do when i go home it is very important that you take your medications as prescribed please go to your scheduled appointment with your primary doctor if you have sudden chest pain which does not stop or gets worse or if your abdominal pain is much worse please tell your primary doctor or go to the emergency room wishes your team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies atenolol amlodipine tekturna felodipine lisinopril diovan attending chief complaint chest pain major surgical or invasive procedure cardiac cath history of present illness ms is a yof w metabolic syndrome hx of diverticulitis tension headaches and ckd stage ii who presents with nonexertional chest discomfort patient reports an acute onset of chest tightness while at rest a few hours prior to arrival she describes pain with associated shortness of breath she had a similar episode yesterday that improved with time her pain is sometimes worse with palpation and occasional improves after belching additionally she reports one week of left upper extremity weakness overall unchanged in the last day she was given asa during transfer to the hospital as well as a sublingual nitro which provided some temporary relief she denies any history of mis and states she had a normal stress test a few years ago denies smoking cigarettes drinking alcohol or using illicit drugs she was briefly admitted to and treated for uncomplicated diverticulitis she had chest pain this admission but no acute ekg changes and negative trops so no further diagnostics were pursued cards was consulted in the ed and given presentation and dynamic ecg changes most consistent with unstable angina they recommended nitro gtt hep gtt and admission to for cath while in the ed her cp persisted with ekg showing new st elevations in v2 v4 and she was taken to the cath lab for stemi in the cath lab she was found to have mid lad occlusion s p pci with one stent w o complications past medical history cad stemi s p occlusion htn dmii diet controlled ckd stage ii started after appendicitis and bacteremia in obesity impingement syndrome left shoulder gerd hld tia social history family history fh htn in mother cva and prostate cancer in father physical admission exam gen nad cv rrr w normal s1 and s2 no m r g pulm ctab abd soft nt nd ext no edema or erythema dischage exam gen nad pleasant heent ncat perrl eomi sclera anicteric neck supple no visible jvd cv rrr s1 s2 no mgr pulm ctab no crackles or wheezes abd soft ndnt no rebound guarding ext no edema b l r radial site looks d c i pertinent results admission labs 40pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 40pm blood glucose urean creat na k cl hco3 angap 40pm blood ctropnt 30am blood ctropnt studies cardiac cath dominance co dominant left main coronary artery the lmca is without flow limiting stenosis left anterior descending the lad has a mid thrombotic ulcerated stenosis with timi flow there is a proximal lad stenosis otherwise without flow limiting stenosis the vessel tappers down to a smaller caliber lad with a larger d3 circumflex the circumflex is without flow limiting stenosis right coronary artery the rca is without flow limiting stenosis impressions single vessel epicardial coronary artery disease with stenosis in the mid lad succesfully treated with des tte the left atrium is normal in size no atrial septal defect is seen by 2d or color doppler the estimated right atrial pressure is mmhg left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the diameters of aorta at the sinus ascending and arch levels are normal the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation there is no mitral valve prolapse the estimated pulmonary artery systolic pressure is normal there is no pericardial effusion impression normal biventriuclar chamber size and global regional systolic function despite known anteriro wall stemi mid lad revascularization on compared with the prior study images reviewed of there has not been a significant change tte the left atrium is normal in size normal left ventricular wall thickness cavity size and global systolic function 3d lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve appears structurally normal with trivial mitral regurgitation the estimated pulmonary artery systolic pressure is normal there is no pericardial effusion impression normal left and right ventricular function normal valvular function discharge labs 35am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 35am blood glucose urean creat na k cl hco3 angap brief hospital course ms is a year old female with htn hld dm ckd ii presenting with cp sob consistent with stemi with mid lad occlusion s p des she had no post catheterization complications and did well post procedurally she was monitored for hours had tte without wall motion abnormalities and was discharged home on asa and ticagrelor stemi s p pci to mid lad occlusion pump lvef rhythm sinus bradycardia rate largely normal tte earlier this year cath w o complications via r radial approach tte did not show wall motion abnormalities the following medication changes were made asa 81mg ticagralor 90mg bid atorvastatin monitor for myalgias pt on rosuvastatin but this was being held for one week prior to admission due to muscle aches started metop xl 50mg daily started lisinopril 5mg daily stopped home diltiazem po chronic issues htn was on diltiazem at home per records intolerant cough to atenolol but no other beta blocker exposure her diltiazem was stopped she was started on lisinopril 5mg and metoprolol 50mg xl at time of discharge with well controlled blood pressures gerd pt reports feeling bloated with epigastric discomfort for prior to presentation possibly angina equivalent vs gerd already on bid ppi epigastric symptoms resolving post pci cont home pantoprazole bid metabolic syndrome hx of dm but no longer taking metformin after normalization of a1c her a1c in house this admission was ckd stage ii baseline appears to be likely dm and htn scr on admission and discharge with baseline around this is mildly elevated above her baseline of and may be related to cin hx diverticulitis treated for uncomplicated diverticulitis on last admission completed antibiotic course with resolution of abdominal pain ct abd showed a right colonic lesion with mesenteric lns with f u recommended at months no abdominal pain n v or diarrhea this admission f u scheduled for hx of transient paresthesia left finger tingling and left cheek numbness that lasted for hours and completely resolved in transitional issues asa and ticagrelor dapt for months minimum years if patient can tolerate patient should go to cardiac rehab changed htn regimen from dilt to lisinopril and metop xr f u bps if high consider uptitrating lisinopril please recheck chem panel within weeks to ensure creatinine back to baseline and to ensure no hyperk on lisinopril monitor for myalgias after initiation of atorvastatin week prior to admission she had had joint pains on rosuvastatin and her pcp had held it her baseline ck measured on was chronic l shoulder pain f u neurology f u regarding transient paresthesia gi f u diverticulitis minutes spent on discharge planning coordination of care please note patient with a history of angioedema patient not aware and had not reported and was not listed in omr to both lisinopril and diovan given that patient was discharged on lisinopril for her blood pressure she was contacted at home on as soon as primary team became aware of this history and she was told to stop taking it she denied any adverse symptoms allergies for both agents entered into omr and communicated with pcp that completed patient plans to follow up with pcp and new cardiologist dr re an alternative regimen for her long standing hypertension medications on admission the preadmission medication list is accurate and complete pantoprazole mg po q12h aspirin ec mg po daily diltiazem extended release mg po daily latanoprost ophth soln drop both eyes qhs rosuvastatin calcium mg po qpm vitamin d unit po daily central vite womens mature multivit min iron fa lutein mg iron mcg mcg oral daily discharge medications atorvastatin mg po qpm rx atorvastatin mg tablet s by mouth at bedtime disp tablet refills lisinopril mg po daily rx lisinopril mg tablet s by mouth daily disp tablet refills metoprolol tartrate mg po bid rx metoprolol tartrate mg tablet s by mouth twice a day disp tablet refills ticagrelor mg po bid to prevent stent thrombosis rx ticagrelor brilinta mg tablet s by mouth twice a day disp tablet refills aspirin mg po daily central vite womens mature multivit min iron fa lutein mg iron mcg mcg oral daily latanoprost ophth soln drop both eyes qhs pantoprazole mg po q12h vitamin d unit po daily discharge disposition home discharge diagnosis primary stemi secondary htn dm gerd ckd 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 the why was i in the hospital you were admitted because you had a heart attack what happened in the hospital you were admitted to the hospital because you had chest pain you were found to have had a heart attack your heart arteries were examined cardiac catheterization which showed a blockage of one of the arteries this was opened by placing a tube called a stent in the artery you were given medications to prevent future blockages what should i do when i go home make sure to take your medication daily it is very important to take your aspirin and ticagrelor also known as brilinta every day these two medications keep the stents in the vessels of the heart open and help reduce your risk of having a future heart attack if you stop these medications or miss dose you risk causing a blood clot forming in your heart stents and having another heart attack please do not stop taking either medication without taking to your heart doctor you are also on other new medications to help your heart such as atorvastatin a stronger statin lisinopril and metoprolol lisinopril and metoprolol will also help with your blood pressure in the place of your previous diltiazem if you start having muscle or joint pains it may be from the atorvastatin please call your primary care doctor or cardiologist to discuss thank you for allowing us to be involved in your care we wish you all the best your healthcare team followup instructions

name unit no admission date discharge date date of birth sex m service psychiatry allergies no known allergies adverse drug reactions attending chief complaint psychiatry consulted by ed team for pt who was referred by therapist at following an incident last night in which he had his pants down and was yelling sexual obscenities major surgical or invasive procedure none history of present illness pt is a m with a history of schizophrenia with prior hospitalization who was referred by therapist at following an incident last night in which he had his pants down and was yelling sexual obscenities pt lives at a group home in and per the clinical director pt has been hypersexual with a number of patients including thrusting behaviors etc the home is planning on expelling him on as a result of these incidents pt denies these incidents claiming his pants were sagging etc there is an open investigation into these incidents pt denies recent changes in mood sleep interest energy appetite weight concentration and memory pt denies si hi history of mania panic symptoms and anxiety he minimizes his prior psych history to a single incident but on further questioning he has a history of paranoia he denies recent worsening of paranoia ior tc tb past medical history past psychiatric history hospitalizations recovery current treaters and treatment pt invega sustenna qmonth last received medication and ect trials unknown self injury denies harm to others hit brother resulting in hospitalization hypersexual behavior per hpi access to weapons denies past medical history none medications including vitamins herbs supplements otc invega sustenna colace cogentin allergies nkda social history social history b r brothers family dad cell mom education graduated high school employment living situation lives at home but will be evicted per hpi relationships marriages children pets single lives in group home as above trauma denies any physical sexual abuse religion legal arrests probations prison hx of being held overnight for annoying the police but pt denies this as a true arrest patient also describes episode of going to court after hitting his brother but brother is alive with no medical complications from incident he notes that at that time he was found incompetent for trial due to his schizophrenia no ongoing legal issues access to weapons none pt states that he feels safe in the group home and that they have a system for ensuring that knives and scissors are hidden substance abuse history pt endorses occasional alcohol use beers several weeks ago with hospitalization due to intoxication no hx withdrawal complications is daily mj user denies other illicit substances smokes cigarettes day forensic history arrests arrested for annoying the police held overnight convictions and jail terms none current status pending charges probation parole family history family psychiatric history denies physical exam weight estimated entered in nursing ipa height patient reported entered in nursing ipa bmi vs bp hr temp resp o2 sat height weight lbs neurological station and gait both wnl narrow based tone and strength normal tone strength grossly wnl moving all extremities freely anti gravity cranial nerves per eomi face grossly symmetrical moves facial musculature grossly symmetrically not drooling nor dysarthric hearing grossly intact voice not hoarse turns heads and shrugs shoulders freely abnormal movements no abnormal movements noted no tremor mental status exam appearance tall well built male calm and polite with good eye contact cooperative behavior and linear historian well groomed behavior cooperative well related appropriate eye contact no notable pmr or pma speech normal rate tone volume prosody intact mood normal a little anxious affect flat thought process linear thought content paranoia as per hpi that people are thinking something negative denies si hi avh iop tc tp judgment insight poor fair cognition arousal level orientation a o x to name date place memory immed recall delayed recall attention intact to moyb calculations quarters language fluent no paraphasic errors prosody intact gen nad cardiac rrr chest ctab normal work of breathing abdom soft non tender extremities warm and dry pertinent results 30pm glucose urea n creat sodium potassium chloride total co2 anion gap 30pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 30pm alt sgpt ast sgot alk phos tot bili 30pm lipase 30pm albumin 30pm asa neg ethanol neg acetmnphn neg bnzodzpn neg barbitrt neg tricyclic neg 50pm urine bnzodzpn neg barbitrt neg opiates neg cocaine neg amphetmn neg oxycodn neg mthdone neg brief hospital course safety the patient was placed on q15 minute checks on admission and remained on that level of observation throughout patient was unit restricted there were no acute safety issues during this hospitalization legal psychiatric on admission to the inpatient unit patient denied engaging in any sexually inappropriate behaviors at his group home either recently or in the past as his group home had reported he felt his sexual urges were under control and had not been increasing in intensity of frequency the patient also denied avh paranoia changes in mood si or hi patient felt his thoughts had been organized thought disorganization was formerly a prominent symptom of his schizophrenia exacerbations but reported that he occasionally blocks things out does not pay attention to things that bother him especially in the setting of recent twice daily marijuana use during admission patient remained in good behavioral control and exhibited no sexually provocative inappropriate gestures or speech home medications were continued including cogentin vitamin d and colace patient had last received his monthly invega sustenna on and did not require further dosing while admitted next due on extensive counseling was provided on marijuana cessation and patient was encouraged to attend substance use support groups while on the unit due to his reported hypersexual behaviors the patient was evicted from his group home during the time he was admitted to deac4 however his father agreed to let the patient live with him in and picked him up on the day of discharge patient was set up with outpatient follow up w therapist and new psychiatric provider at and provided with paper prescriptions the patient s current presentation was felt to be most consistent with a substance induced exacerbation of disinhibition impulsivity and poor judgment on the background of chronic schizophrenia notably the patient did not appear grossly psychotic and he exhibited no hypersexual or inappropriate behaviors in the setting of abstinence from substance use general medical conditions patient was continued on home colace and vitamin d psychosocial groups milieu patient was encouraged to participate in the unit s groups milieu therapy opportunities he attended the majority of groups and was noted to participate appropriately often seen conversing with staff use of coping skills and mindfulness relaxation methods were encouraged therapy addressed family social work issues collateral contacts family contacts collateral was obtained from father director of group home and director of the spot program family discussions were held with the patient father social work nursing and treatment team mds that focused psychoeducation and discharge planning interventions medications home cogentin psychotherapeutic interventions individual group and milieu therapy coordination of aftercare by treatment team and outpatient providers informed consent no new medications were started during this hospitalization risk assessment chronic static risk factors age male gender chronic mental illness history of substance use modifiable risk factors recent active daily substance use modified by providing a drug free environment drug use counseling and unit aa smart recovery meetings protective factors medication adhearance monthly invega injections connection to outpatient treaters social support parents no active mood disturbance or suicidal ideation no active psychosis connection to stable living situation with father prognosis patient presented with significant reported behavioral disturbances that interfered with psychosocial functioning prognosis is guarded due to concern for continued substance use in the outpatient setting however is improved by connection to outpatient treaters social support and depot antipsychotic the patient was taught about warning signs and understands that there are many resources including the emergency department that he can follow up with medications on admission the preadmission medication list is accurate and complete paliperidone palmitate mg im q1mo benztropine mesylate mg po qhs docusate sodium mg po qhs vitamin d unit po daily discharge medications benztropine mesylate mg po qhs rx benztropine mg one tablet s by mouth at bedtime disp tablet refills docusate sodium mg po qhs rx docusate sodium mg one capsule s by mouth at bedtime disp capsule refills paliperidone palmitate mg im q1mo vitamin d unit po daily rx ergocalciferol vitamin d2 unit one tablet s by mouth once a day disp tablet refills discharge disposition home discharge diagnosis schizophrenia marijuana use disorder discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent appearance tall athletic appearing male well groomed good hygiene wearing own clothing behavior sitting with arms at side polite and cooperative appropriate eye contact speech normal rate volume prosody intact monotonous mood affect good blunted mild fluctuations appropriate to topic of conversation thought process linear goal directed thought content denies si hi avh iop tc tp paranoia judgment insight fair fair memory grossly intact attention grossly intact to interview language fluent no paraphasic errors prosody intact station and gait both discharge instructions you were hospitalized at for reported concerning behaviors in the setting of substance use and concern for worsening schizophrenia while you were here we continued your medications and arranged a safe discharge plan you are now ready for discharge with continued treatment with your outpatient providers please follow up with all outpatient appointments as listed take this discharge paperwork to your appointments please continue all medications as directed please do not misuse alcohol or drugs whether prescription drugs or illegal drugs as this can further worsen your medical and psychiatric illnesses please contact your outpatient psychiatrist or other providers if you have any concerns please call or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers it was a pleasure to have worked with you and we wish you the best of health followup instructions

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 cabg x lima lad rsvg ramus pda history of present illness mr is a year old m w pmh htn hld bph who presents with week of chest pain pt has good comprehension and limited expression interviewed w son acting as interpreter he reports that he started having doe weeks ago which started before going on a cruise last week had episodic cp radiating to l shoulder first occurring only with exertion then occasionally at rest when he experienced anxiety about days got back from cruise ate lunch with son called pcp and had cp so was biba got ntg tabs and full dose asa in the ambulance at bedside he is cp free has no dyspnea cough in the ed initial vs were ra exam notable for jvp not elevated ctab rrr no m r g no lower extremity edema ekg from ambulance shows avr elevation st depressions diffusely ekg at bedside shows st depressions in avf j point elevation in v1 v2 labs showed wbc cr trop imaging showed cxr w no acute intrathoracic abnormality cardiology consulted and recommended admission and plan for cath tomorrow am for nstemi patient received atorvastatin mg iv heparin gtt transfer vs were ra on arrival to the floor patient reports that he has never had any chest pain or sob like this generally active man and works in his garden without any symptoms feeling better now with no chest pain or left radiation of pain no sob no lower extremity edema past medical history htn hld diet controlled bph stomach ulcer s p surgery in colonoscopies at bi n in w large tubular adenoma last section removed social history family history none physical exam admission physical exam vs ra general nad heent at nc eomi perrl anicteric sclera pink conjunctiva mmm neck supple no lad no jvd heart rrr s1 s2 no murmurs gallops or rubs lungs ctab no wheezes rales rhonchi breathing comfortably without use of accessory muscles abdomen nondistended 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 vital signs and intake output temp po bp l lying hr rr o2 sat o2 delivery 1l total intake 660ml total output 1325ml physical examination general neuro nad x a o x3 x non focal x cardiac rrr x irregular nl s1 s2 x lungs cta x diminished bases no resp distress x abd nbs x soft x mildly distended x nt x extremities trace cce x pulses doppler palpable x wounds sternal cdi x no erythema or drainage x sternum stable x prevena leg right left x cdi x no erythema or drainage x other pertinent results 30am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30am blood 30am blood glucose urean creat na k cl hco3 angap pa and lateral compared the prior examination right ij central venous catheter remains in place there remain postoperative changes from cabg mild to moderate cardiomegaly is unchanged there remains central pulmonary vascular congestion with trace interstitial edema perhaps slightly worsened compared to the prior examination a small to moderate right sided pleural effusion and small left sided pleural effusion appears slightly increased in volume with adjacent compressive atelectasis no other superimposed consolidation is seen there is no pneumothorax there is no acute osseous abnormality subcutaneous gas is likely postoperative and appears slightly improved tte the estimated right atrial pressure is mmhg overall left ventricular systolic function is normal lvef there is low normal free wall contractility there is a small pericardial effusion loculated posteriorly along the inferolateral left ventricular free wall there are no echocardiographic signs of tamponade impression small loculated pericardial effusion without echocardiographic signs of tampoande a right pleural effusion is present compared with the prior study images reviewed of left atrial diastolic collapse is not seen size of the effusion is similar intra op tee 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 the left ventricular cavity size is normal overall left ventricular systolic function is normal lvef the right ventricular cavity is mildly dilated with borderline normal free wall function there are complex 4mm atheroma in the ascending aorta there are focal calcifications in the aortic arch there are complex 4mm atheroma in the descending thoracic aorta 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 an anterior fat pad post bypass the patient is in sinus rhythm and receiving a phenylephrine infusion left ventricular function remains normal right ventricular function is more vigorous and appears normal valvular function remains unchanged there is no pericardial effusion the thoracic aorta is intact following decannulation was notified in person of the results at the time the exam was performed in the operating room brief hospital course mr is a year old m w pmh htn hld bph who presented with week of chest pain ekg with st depressions trops elevated consistent with nstemi the patient was started on medical management with heparin gtt asa atorvastatin metoprolol he underwent cardiac cath which showed diffuse vessel disease he was thus continued on heparin drip until he underwent cabg on he was taken to the operating room where he underwent coronary artery bypass grafting please see operative note for detail 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 he had a tte on pod due to acute hypotension which showed moderate sized serous loculated pericardial effusion inferior to the left atrium he remained hemodynamically stable with this finding pod he went into rapid atrial fibrillation and was given an amiodarone bolus and drip which transitioned to oral amiodarone beta blocker was initiated and the patient was gently diuresed toward the preoperative weight he was started on coumadin for post op atrial fibrillation this converted to sinus rhythm by the time the patient was discharged the patient was transferred to the telemetry floor for further recovery he was transfused unit l rbc on pod due to post op anemia and soft blood pressure hematocrit was stable at the time of discharge the patient underwent a tte on which showed that the pericardial effusion was unchanged in size due to mild orthostatic hypotension his lasix was held and he will not be discharged on lasix chest tubes and pacing wires were discontinued without complication 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 with assistance the wound was healing and pain was controlled with oral analgesics the patient was discharged to at in good condition with appropriate follow up instructions medications on admission the preadmission medication list may be inaccurate and requires futher investigation aspirin mg po daily tamsulosin mg po qhs discharge medications acetaminophen mg po q6h prn pain mild amiodarone mg po bid take 200mg bid for weeks then take 200mg daily for weeks then stop atorvastatin mg po qpm docusate sodium mg po bid prn constipation metoprolol tartrate mg po tid oxycodone immediate release mg po q4h prn pain moderate severe rx oxycodone mg tablet s by mouth every four hours disp tablet refills polyethylene glycol g po daily senna mg po bid prn constipation first line md to order daily dose po daily16 dose per rehab team 5mg given on aspirin mg po daily tamsulosin mg po qhs discharge disposition extended care facility discharge diagnosis nstemi htn denies hld diet controlled denies bph 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 trace 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 followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies penicillins nutrasweet aspartame sulfa sulfonamide antibiotics attending chief complaint abdominal pain ams major surgical or invasive procedure none history of present illness ms is a pmhx chronic pain on methadone chronic ble venous stasis ulcers and recurrent utis who presents with ams and abdominal pain history is predominant obtained from son and sign out as patient is limited by her mental status patient at baseline requires intermittent straight catheterizations due to intermittent trouble with initiating urinary stream days ago she reportedly developed new urinary incontinence and symptoms of dysuria as well as malorous urine c w prior uti she also has been having days of suprapubic abdominal pain since yesterday she also developed new intermittent confusion and disorientation in the initial vs on ra initial labs were notable for na k cr wbc hgb baseline hgb plt lactate ua grossly positive with mod leuks sm bld positive nitrites wbc and few bacteria she was given ceftriaxone prior to transfer to the floor given agitation she required olanzapine x in the prior to transfer upon arrival to the floor the patient states that her son is transitioning her care from to the patient reports significant suprapubic discomfort and states that she has to urinate she states that she self catheterizes herself at home intermittently but cannot explain to me what her underlying urologic issue is and if she has seen urology in the past she does not know if her ble edema is stable review of systems per hpi fever chills night sweats headache vision changes rhinorrhea congestion sore throat cough shortness of breath chest pain diarrhea constipation brbpr melena hematochezia dysuria hematuria past medical history htn hypothyroidism chronic venous stasis ulcers recurrent utis chronic pain back injury nos asthma copd rheumatoid arthritis t2dm social history family history nc physical exam admission physical exam vitals ra general well appearing elderly female lying in bed in nad heent mmm ncat eomi anicteric sclera cardiac rrr nml s1 and s2 no m r g lungs clear to auscultation bilaterally unlabored respirations abdomen soft obese somewhat distended extremities wwp chronic venous stasis changes bilaterally with scattered healing wounds skin chronic venous stasis changes as above neurologic aox2 able to state month states she is in a hospital and to self grossly nonfocal discharge physical exam vital signs po ra general elderly woman sitting up in bed heent mmm anicteric sclera cardiac rrr lungs ctab no accessory muscle use abdomen soft obese non tender non distended extremities wwp chronic venous stasis changes bilaterally with scattered healing wounds dressing that is c d i skin chronic venous stasis changes as above neurologic alert oriented to hospital and to self moving all extremities pertinent results 54pm urine color yellow appear hazy sp 54pm urine blood sm nitrite pos protein glucose neg ketone neg bilirubin neg urobilngn ph leuk mod 54pm urine rbc wbc bacteria few yeast none epi 54pm urine mucous occ 57pm lactate 48pm glucose urea n creat sodium potassium chloride total co2 anion gap 48pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 48pm neuts lymphs monos eos basos im absneut abslymp absmono abseos absbaso 48pm plt count micro bcx x pending ucx pending imaging studies none micro pm urine final report urine culture final staph aureus coag cfu ml oxacillin resistant staphylococci must be reported as also resistant to other penicillins cephalosporins carbacephems carbapenems and beta lactamase inhibitor combinations sensitivities mic expressed in mcg ml staph aureus coag gentamicin s levofloxacin r nitrofurantoin s oxacillin r tetracycline s trimethoprim sulfa s vancomycin s blood cultures negative tte the left atrium is mildly dilated 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 an increased left ventricular filling pressure pcwp 18mmhg right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened no masses or vegetations are seen on the aortic valve but cannot be fully excluded due to suboptimal image quality there is no aortic valve stenosis trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse no mass or vegetation is seen on the mitral valve physiologic mitral regurgitation is seen within normal limits the tricuspid valve leaflets are mildly thickened no masses or vegetations are seen on the tricuspid valve but cannot be fully excluded due to suboptimal image quality the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression suboptimal image quality no echocardiographic evidence of endocarditis or pathologic flow mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function elevated pcwp suggested mri impression incomplete examination with acquisition of localizer and sagittal t2 images only provided images demonstrate levoscoliosis with moderate to severe l3 l4 and severe l4 l5 spinal canal stenosis with moderate to severe multilevel neural foraminal narrowing as detailed above recommend repeat examination when the patient is able to better tolerate the entire exam suboptimal evaluation for epidural fluid collection on this study although there is no obvious evidence discharge labs 57am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 57am blood glucose urean creat na k cl hco3 angap brief hospital course ms is a pmhx chronic ble venous stasis ulcers and recurrent utis who presents with ams and uti abdominal pain likely complicated mrsa uti urinary retention patient with history of recurrent utis within past years per son she is likely at risk for utis in the setting of urinary stasis it is unclear why the patient requires intermittent self catheterization she has been referred to uro gyn by her pcp but unclear if she actually attended any visits per son she has history of a lady cancer with episodes of recurrence necessitating chemo randiation last was years ago ct scan without clear etiology for pain urine culture with mrsa in urine no growth in blood cultures mri as suboptimal study but without clear epidural collection in the setting of mrsa bactermia up to of patients with have bacteruria but in studies of patients with mrsa bacteruria only in patients has mrsa bactermia mri l spine incomplete study but no definitive abscess and patient would like to not complete pain at baseline level tte suboptimal study but no frank vegetations and negative blood cultures make risk of tee higher than benefit she was treated with iv vancomycin and then transitioned to doxycycline given sulfa allergy will not use bactrim for complicated uti for day course when her blood culture finalized as negative encephalopathy likely induced in the setting of acute infection as described above patient without other evidence of metabolic derangements at this time home methadone and pain regimen initially held and then restarted slowly as mental status improved she returned to her baseline mental status concern for elder abuse patient reported verbal abuse from her son with whom she lives with no evidence of physical abuse on my exam mental status is improved and long discussion with pcp and sw i spoke for some time about the situation with her son she reports that he is not physically abusive but is verbally and is nervous about him when we discussed she reports that she does not want to move forward with a police filing or a restraining order because of what it would do to her family i was also able to speak with her pcp for about minutes who reports that they have had similar concerns but that she has declined reporting in the past due to the same concerns her pcp reports that she can be difficult to engage in follow up be reported that at her baseline which she is at she has been found to have capacity to make her own decisions as well social work was involoved and relayed information to the open elder services case hypothyroidism tsh is very abnormal though notably with normal free t4 home levothyroxine continued chronic pain rheumatoid arthritis home prednisone continued home methadone continued home oxycodone restarted htn continued home losartan amlodipine triamterene hctz hld continued home statin depression continued home sertraline gerd continued home omeprazole t2dm home metformin held and patient managed with iss restarted at discharge medications on admission the preadmission medication list may be inaccurate and requires futher investigation albuterol sulfate mcg actuation inhalation q6h prn amlodipine mg po daily atorvastatin mg po qpm gabapentin mg po qid levothyroxine sodium mcg po daily losartan potassium mg po daily metformin xr glucophage xr mg po daily methadone mg po qhs acetaminophen mg po q4h prn pain mild aspirin mg po daily methotrexate mg po frequency is unknown nabumetone mg po bid omeprazole mg po daily sertraline mg po daily prednisone mg po daily triamterene hctz cap po daily discharge medications docusate sodium mg po bid doxycycline hyclate mg po q12h rx doxycycline hyclate mg capsule s by mouth every twelve hours disp capsule refills senna mg po bid prn constipation oxycodone immediate release mg po q8h prn pain severe rx oxycodone mg tablet s by mouth every hours disp tablet refills acetaminophen mg po q4h prn pain mild albuterol sulfate mcg actuation inhalation q6h prn amlodipine mg po daily aspirin mg po daily atorvastatin mg po qpm levothyroxine sodium mcg po daily losartan potassium mg po daily metformin xr glucophage xr mg po daily methadone mg po qhs rx methadone mg mg by mouth at bedtime disp tablet refills methotrexate mg po qsun multivitamins tab po daily nabumetone mg po bid omeprazole mg po daily prednisone mg po daily sertraline mg po daily triamterene hctz cap po daily held gabapentin mg po qid this medication was held do not restart gabapentin until follow up with pcp discharge disposition extended care facility discharge diagnosis urinary tract infection encephalopathy discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions you were admitted for confusion and concern for urinary tract infection you were treated with iv antibiotics and found to have a mrsa uti you were investigated for a bloodstream source ant it was negative both tte and mri did not show any focus of infection please take your medications as directed and follow up with your pcp once discharge followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies penicillins nutrasweet aspartame sulfa sulfonamide antibiotics attending chief complaint bilateral leg pain major surgical or invasive procedure none history of present illness ms is a year old woman with a history of hypothyroidism rheumatoid arthritis chronic pain dm ii hypertension who presents with days of bilateral leg pain she reports that she has had no inciting trauma or exposure but that days ago she began noticing increasing pain in her bilateral legs along with increased redness she presented to the ed on but left before being evaluated by a physician she now presents to for further evaluation in the ed initial vitals pain ra exam notable for alert patient occasionally moaning in pain bilateral lower extremities with marked edema well demarcated erythema tender to palpation labs notable for wbc hgb plt chemistry with k and otherwise wnl lactate imaging notable for none obtained pt given methadone mg x1 oxycodone mg vancomycin 1g admission requested for management of cellulitis vitals prior to transfer ra on the floor the patient is restless due to the foley that was placed in the ed she persistently gets out of bed as she feels that standing will help the urine come out review of systems denies fever chills weight change headache cough shortness of breath chest pain nausea vomiting diarrhea constipation she straight catheterizes at home due to incomplete bladder emptying but cannot quantify how often she straight caths urgency no dysuria past medical history htn hypothyroidism chronic venous stasis ulcers recurrent utis chronic pain back injury nos asthma copd rheumatoid arthritis t2dm social history family history patient states her family had medical conditions but she cannot describe more specifically physical exam discharge vitals t bp hr rr22 o2sat ra heent sclerae anicteric mmm oropharynx clear eomi perrl neck supple jvp not elevated no lad cv regular rate and rhythm normal s1 s2 no murmurs rubs gallops lungs clear to auscultation bilaterally no wheezes rales rhonchi abdomen soft mid abdominal tenderness to palpation non distended bowel sounds present no organomegaly no rebound or guarding gu no foley ext well demarcated venous stasis changes with lower extremity edema bilaterally right lower extremity with superficial ulceration on the ventral and dorsal aspect no pain elicited with moderate pressure neuro cnii xii intact strength upper lower extremities grossly normal sensation reflexes bilaterally gait deferred oriented to self but not to date pertinent results on admission 25pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 25pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 25pm blood glucose urean creat na k cl hco3 angap 30pm blood lactate microbiology urine culture pending blood culture pending on discharge 12am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 12am blood glucose urean creat na k cl hco3 angap 12am blood calcium phos mg 30pm blood lactate ssessment and plan ms is a year old woman with a history of chronic pain rheumatoid arthritis chronic venous stasis hypertension hyperlipidemia who presents with days of worsening bilateral lower extremity pain admitted given concern for cellulitis found to have chronic lymphedema bilateral leg pain chronic venous stasis patient presents from home with worsening bilateral leg pain admitted with concern for cellulitis she is s p a dose of vancomycin in the ed exam however is more consistent with severe bilateral venous stasis with superficial skin tears noted on the right lower extremity patient afebrile and without white count to further raise suspicion for cellulitis additionally patient without pain on exam with moderate pressure applied to her lower extremities consulted wound care who felt this was was lymphedema and wrapped her legs with improvement we set her up with a for wound care at home she will need close follow up concern for elder abuse review of last discharge summary reveals reported verbal abuse from her son with whom she lives patient did not want to move forward with a police filing or a restraining order pcp is aware of the situation patient has declined reporting in the past due to concerns about what such a report would do to her family pcp reported that the patient has had capacity to make her own decisions social work was involved on the last admission and relayed the information to the open elder services case social work remains involved and she has ongoing support hypothyroidism tsh checked during last admission noted to be abnormal though with normal free t4 will continue home levothyroxine chronic pain rheumatoid arthritis continue home prednisone continue home methadone continue home oxycodone methotrexate htn hypertensive on arrival though patient cannot remember when she last took her medications continue home losartan amlodipine triamterene hctz hld continue home statin depression continue home sertraline gerd continue home omeprazole t2dm will hold home metformin and will treat with insulin sliding scale urinary retention patient straight catheterizes at home though on admission patient cannot recall how often foley was placed in the ed ua without evidence of uti will plan to remove foley in am and resume straight catheterization minutes was spent on this complicated discharge medications on admission the preadmission medication list is accurate and complete acetaminophen mg po q4h prn pain mild amlodipine mg po daily aspirin mg po daily atorvastatin mg po qpm levothyroxine sodium mcg po daily losartan potassium mg po daily methadone mg po qhs multivitamins tab po daily omeprazole mg po daily oxycodone immediate release mg po q8h prn pain severe prednisone mg po daily sertraline mg po daily triamterene hctz cap po daily docusate sodium mg po bid senna mg po bid prn constipation albuterol sulfate mcg actuation inhalation q6h prn gabapentin mg po qid metformin xr glucophage xr mg po daily methotrexate mg po qsun nabumetone mg po bid discharge medications acetaminophen mg po q4h prn pain mild albuterol sulfate mcg actuation inhalation q6h prn amlodipine mg po daily aspirin mg po daily atorvastatin mg po qpm docusate sodium mg po bid gabapentin mg po qid levothyroxine sodium mcg po daily losartan potassium mg po daily metformin xr glucophage xr mg po daily methadone mg po qhs methotrexate mg po qsun multivitamins tab po daily nabumetone mg po bid omeprazole mg po daily oxycodone immediate release mg po q8h prn pain severe prednisone mg po daily senna mg po bid prn constipation sertraline mg po daily triamterene hctz cap po daily discharge disposition home with service facility discharge diagnosis lymphedema chronic 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 were admitted when had increased pain in your legs intially were worried this was an infection your legs were examined and the redness and swelling were consistent with chronic lymphedema lymphedema is a progressive disorder of the lymphatic system that results in the accumulation of interstitial fluid and tissue your skin was not infected were seen by the wound nurse who recommended ace wrap your legs will now have a visiting nurse to help manage your leg swelling and skin care will need to closely follow with your primary care doctor it was a pleasure caring for your doctors instructions

name unit no admission date discharge date date of birth sex f service medicine allergies penicillins nutrasweet aspartame sulfa sulfonamide antibiotics attending chief complaint leg lesions major surgical or invasive procedure none history of present illness pmh chronic low back pain on narcotics agreement who presents with cc of bilateral lower extremity pain after a fall one week ago per ed the patient states she slipped and fell in her hallway and went to the hospital week ago she doesn t remember which hospital but thinks it might have been bwh she does not recall if she hit her head or if she had any imaging of her head or back done she is endorsing low back pain that is worse than her chronic low back pain she denies any fecal incontinence or saddle anesthesia she says that when she feels the urge to urinate she doesn t always feel like she empties her bladder completely but this has been going on since before her fall she reports that when she fell she also scraped her legs even before this both of her legs were very itchy and she was prescribed some topical cream by her outpatient provider which was helping somewhat she thinks however that this has all gotten worse since the fall she thinks she has been scratching her legs in her sleep and is worried about the abrasions on her legs she says that normally her legs are a little red below the knee but that the current redness and skin breakdown are worse than is typical for her she denies any fevers chills n v d lightheadedness on ed exam they noted that the patient was alert but confused at times with bony tenderness along lumbar spine strength bilateral lower extremities they noted her bilateral lower extremities were erythematous with pitting edema to the knee several areas of superficial abrasions and skin break down excoriations present ed covered for cellulitis and uti noted concern re delirium of note the patient was pulling out ivs and confused in ed reviewed vs labs orders images old records meds vs tmax 35pm blood hgb 55pm blood hgb 35pm blood mcv 12am blood hgb 35pm blood creat 11pm urine blood neg nitrite neg protein glucose neg ketone neg bilirub neg urobiln ph leuks mod 11pm urine rbc wbc bacteri few yeast none epi transe pm urine urine culture pending pm blood culture blood culture routine pending pm blood culture blood culture routine pending patient is s p iv ceftriaxone started iv vancomycin mg ordered started iv ceftriaxone g stopped 1h po doxycycline hyclate not given po ng atorvastatin not given imaging bilateral duplex impression no evidence of deep venous thrombosis in the right or left lower extremity veins limited evaluation of the peroneal veins enlarged bilateral inguinal lymph nodes measuring x cm on the right and x cm on the left slightly enlarged compared to and nonspecific ct l spine w o contrast chronic degenerative changes with acute fracture or new malignment cth w o contrast no acute hemorrhage no notable change compared to prior diffuse hypodensities in the white matter are again seen similar in extent to these findings could be related to prior therapy or due to extensive small vessel disease if clinically indicated nonemergent mri with gadolinium could be helpful for further assessment of these findings as mri is more sensitive for intracranial metastases and post treatment changes i interviewed patient she was fairly lucid very mildly confused was able to tell jokes she notes that she fell and hurt her back a week ago and was worked up for this fall at another hospital which may have been she notes that her legs over the past few days have become more painful and while she can walk it is more difficult she denies fever chills sob nausea vomiting diarrhea past medical history chronic pain years back hands rheumatic fever rheumatoid arthritis htn hld type dm asthma cervical ca s p hysterectomy uterine ca hypothyroidism venous stasis depression anxiety htn hypothyroidism chronic venous stasis ulcers recurrent utis chronic pain back injury nos asthma copd rheumatoid arthritis t2dm social history family history patient states her family had medical conditions but she cannot describe more specifically physical exam admission physical exam vitals afebrile and vital signs stable see eflowsheet general alert and in no apparent distress eyes anicteric pupils equally round ent ears and nose without visible erythema masses or trauma oropharynx without visible lesion erythema or exudate cv heart regular no murmur no s3 no s4 no jvd resp lungs clear to auscultation with good air movement bilaterally breathing is non labored gi abdomen soft non distended non tender to palpation bowel sounds present no hsm gu no suprapubic fullness or tenderness to palpation msk neck supple moves all extremities strength grossly full and symmetric bilaterally in all limbs skin bilateral lower extremity edema and multiple scabbed lesions neuro alert oriented face symmetric gaze conjugate with eomi speech fluent moves all limbs sensation to light touch grossly intact throughout psych pleasant appropriate affect mildly confused discharge physical exam vitals 2po ra general alert and in no apparent distress eyes anicteric pupils equally round ent ears and nose without visible erythema masses or trauma oropharynx without visible lesion erythema or exudate cv heart regular no murmur no s3 no s4 no jvd resp lungs clear to auscultation with good air movement bilaterally breathing is non labored gi abdomen soft non distended non tender to palpation bowel sounds present no hsm gu no suprapubic fullness or tenderness to palpation msk neck supple moves all extremities strength grossly full and symmetric bilaterally in all limbs skin bilateral lower extremity edema and multiple scabbed lesions noted erythema in legs bilaterally neuro alert oriented face symmetric gaze conjugate with eomi speech fluent moves all limbs sensation to light touch grossly intact throughout psych pleasant appropriate affect pertinent results admission labs 35pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 49am blood ptt 35pm blood glucose urean creat na k cl hco3 angap 49am blood alt totbili 49am blood albumin calcium phos mg 11pm urine color yellow appear clear sp 11pm urine blood neg nitrite neg protein glucose neg ketone neg bilirub neg urobiln ph leuks mod 11pm urine rbc wbc bacteri few yeast none epi transe 11pm urine casthy microbiology pm urine final report urine culture final enterococcus sp cfu ml sensitivities mic expressed in mcg ml enterococcus sp ampicillin s nitrofurantoin s tetracycline s vancomycin s blood cultures x pending ngtd imaging bilateral doppler ultrasound impression no evidence of deep venous thrombosis in the right or left lower extremity veins limited evaluation of the peroneal veins enlarged bilateral inguinal lymph nodes measuring x cm on the right and x cm on the left slightly enlarged compared to and nonspecific ct c spine w o contrast the mild anterolisthesis of c2 on c3 which is likely degenerative in nature given overall degenerative change of cervical spine and lack of overlying prevertebral soft tissue swelling no priors are available for comparison to assess for chronicity of this finding moderate to severe degenerative changes throughout the remaining cervical spine most severe at c3 causing at least moderate spinal canal narrowing no acute fracture of the cervical spine ct l spine w o contrast chronic degenerative changes with acute fracture or new malignment cth w o contrast no acute hemorrhage no notable change compared to prior diffuse hypodensities in the white matter are again seen similar in extent to these findings could be related to prior therapy or due to extensive small vessel disease if clinically indicated nonemergent mri with gadolinium could be helpful for further assessment of these findings as mri is more sensitive for intracranial metastases and post treatment changes discharge labs 13am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 13am blood glucose urean creat na k cl hco3 angap 13am blood calcium phos mg year old woman with history notable for chronic low back pain on narcotics agreement methadone nabumetone rheumatoid arthritis chronic venous stasis and ulceration who presented with lower extremity pain after a fall one week ago and found to have delirium positive urinalysis and concern for bilateral lower extremity cellulitis active issues urinary tract infection encephalopathy suspect secondary to infection concern for cellulitis as below though ua positive growing enterococcus started on ceftriaxone d1 received three days of treatment bilateral lower extremity pain chronic venous insufficiency initially concerned for bilateral lower extremity cellulitis though wounds on the bilateral legs did not appear infected they were not warm and had superficial ulceration with serous discharge only she had no fever leukocytosis or other systemic signs of infection treated initially with vancomycin and levofloxacin though discontinued due to low concern for cellulitis rn evaluated patient and left wound care instructions chronic issues chronic anemia hemoglobin fluctuates generally normocytic hemoglobin remained stable during her admission chronic low back pain on narcotics agreement reviewed by admitting md methadone and oxycodone and nabumetone hypertensino continued amlodipine hyperlipidemia continued statin diabetes metformin was held sliding scale insulin was administered during admission asthma continued albuterol prn rheumatoid arthritis continued prednisone 5mg per day patient does not appear to be in flare would recommend she follow up outpatient regarding tapering chronic steroids hypothyroidism continued levothyroxine depression and anxiety continued sertraline copd continued albuterol prn transitional issues follow up patient will be going to rehab on ct head she was found to have diffuse hypodensities in the white matter are again seen similar in extent to these findings could be related to prior therapy or due to extensive small vessel disease if clinically indicated nonemergent mri with gadolinium could be helpful for further assessment of these findings as mri is more sensitive for intracranial metastases and post treatment changes code status full code medications on admission the preadmission medication list is accurate and complete acetaminophen mg po q4h prn pain mild amlodipine mg po daily aspirin mg po daily atorvastatin mg po qpm docusate sodium mg po bid gabapentin mg po qid levothyroxine sodium mcg po every losartan potassium mg po daily methadone mg po q8h prn severe back pain multivitamins tab po daily omeprazole mg po daily oxycodone immediate release mg po q8h prn breakthrough pain prednisone mg po daily senna mg po bid prn constipation sertraline mg po daily triamterene hctz cap po daily albuterol sulfate mcg actuation inhalation q6h prn metformin xr glucophage xr mg po daily methotrexate mg po qsun nabumetone mg po bid nitroglycerin sl mg sl q5min prn chest pain travatan z travoprost ophthalmic eye qhs triamcinolone acetonide ointment appl tp bid lesions discharge medications acetaminophen mg po q4h prn pain mild albuterol sulfate mcg actuation inhalation q6h prn amlodipine mg po daily aspirin mg po daily atorvastatin mg po qpm docusate sodium mg po bid gabapentin mg po qid levothyroxine sodium mcg po every losartan potassium mg po daily metformin xr glucophage xr mg po daily methadone mg po q8h prn severe back pain rx methadone mg tab by mouth every eight hours disp tablet refills methotrexate mg po qsun multivitamins tab po daily nabumetone mg po bid nitroglycerin sl mg sl q5min prn chest pain omeprazole mg po daily oxycodone immediate release mg po q8h prn breakthrough pain rx oxycodone mg capsule s by mouth every eight hours disp capsule refills prednisone mg po daily senna mg po bid prn constipation sertraline mg po daily travatan z travoprost ophthalmic eye qhs triamcinolone acetonide ointment appl tp bid lesions triamterene hctz cap po daily discharge disposition extended care facility discharge diagnosis urinary tract infection 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 you were admitted to the hospital with pain in your legs due to swelling and ulcers from chronic venous insufficiency but no cellulitis you were also found to be rather confused this was due to a urinary tract infection we treated you with antibiotics and you improved it is important that you continue to take your medications as prescribed and follow up with the appointments listed below good luck followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies penicillins nutrasweet aspartame sulfa sulfonamide antibiotics attending chief complaint ams major surgical or invasive procedure none history of present illness ms is a female with history of rheumatoid arthritis on daily prednisone htn hld hypothyroidism dm2 asthma depression anxiety who presents with ams the patient s son is not present but the patient tells me that he brought her to the ed she says he s an ex he thinks he knows everything but knows nothing i think he jumped the gun bringing me here overreading into things she was noted to be reportedly lethargic in the ed the patient is oriented to and can recite the days of the weeks backwards she says she has had days of malaise and feeling overall unwell no myalgias subjective fever nausea vomiting dysuria hematuria however she does have suprapubic discomfort the past days she denies flank or back pain no dyspnea or chest pain of note she was admitted discharged for ams due to uti and found to have enterococcus as outpatient she had urine culture for urinary urgency dysuria by pcp and that showed gbs she completed a day course of macrobid for that ed got iv tylenol iv vanc iv ctx for presumed uti past medical history chronic pain years back hands rheumatic fever rheumatoid arthritis htn hld type dm asthma cervical ca s p hysterectomy uterine ca hypothyroidism venous stasis depression anxiety htn hypothyroidism chronic venous stasis ulcers recurrent utis chronic pain back injury nos asthma copd rheumatoid arthritis t2dm social history family history patient states her family had medical conditions but she cannot describe more specifically physical exam vitals afebrile and vital signs stable see eflowsheet general sitting up in chair eyes anicteric pupils equally round ent ears and nose without visible erythema masses or trauma cv heart regular no murmur resp lungs clear to auscultation with good air movement bilaterally breathing is non labored gi abdomen soft non distended mildly ttp across upper abdomen bowel sounds present msk neck supple moves all extremities neurologic oriented to person place and situation pertinent results 06am blood tsh ct abd bladder appears mildly inflamed correlate for cystitis no signs of pyelonephritis marked degenerated disease at l4 similar to prior better assessed on prior ct and mri please correlate clinically renal hypodensities possibly cysts several too small to characterize am urine final report urine culture final escherichia coli cfu ml cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h sensitivities mic expressed in mcg ml escherichia coli ampicillin r ampicillin sulbactam r cefazolin s cefepime s ceftazidime s ceftriaxone s ciprofloxacin s gentamicin s meropenem s nitrofurantoin s piperacillin tazo s tobramycin s trimethoprim sulfa r brief hospital course ms is a female with history of rheumatoid arthritis on daily prednisone htn hld hypothyroidism niddm2 asthma depression anxiety who presents with ams and fever found to have a uti uti metabolic encephalopathy the patient presented with increased frequency of urination foul smelling urine and disorientation pt s ucx grew ecoli that was sensitive to ctx and cipro pt improved after iv ceftriaxone and was transitioned to po cipro to complete a 7d course last day for complicated uti pt was then discharged to rehab when discussing a discharge plan with the patient she reported that she would like to stay in the hospital a little longer when asked why this was the case she alluded to issues at home and with her son with whom she lives she explained that her son is a former and has anger management issues she reported theft of her personal property and suggested verbal abuse before providing more details however the patient became very nervous and shut down expressing regret that she said anything at all fearful of suffering retaliation based on patient s reports in the morning an online eps report was filed slow transit constipation exacerbated by chronic opioid use employing docusate senna polyethylene glycol and bisacodyl suppositories titrated to have daily bowel movements rheumatoid arthritis pt s home 5mg pred was continued of note on presentation due to concerns for sepsis pt received one dose of stress dose steroids 100mg hydrorcortisone iv x1 which were then discontinued when pt was stable upon arrival to the floor niddm2 ssi while inpatient held home oral agents resume at discharge htn continued home losartan amlodipine hctz triamterene hld continued home statin anxiety continued home zoloft hypothyroidism continued home synthroid takes weekly mcg kg x7 to help with compliance tsh was elevated at and the patient s son reported she has not been taking at home transitional on ct a p marked degenerated disease at l4 similar to prior better assessed on prior ct and mri nothing on exam to suggest myelopathy at this time for outpatient follow up complete ciprofloxacin mg q12 hr on ms was seen and examined on the day of discharge is clinically stable for discharge today the total time spent today on discharge planning counseling and coordination of care today was greater than minutes medications on admission the preadmission medication list is accurate and complete acetaminophen mg po q4h prn pain mild amlodipine mg po daily aspirin mg po daily atorvastatin mg po qpm docusate sodium mg po bid losartan potassium mg po daily methadone mg po q8h prn severe back pain nabumetone mg po bid nitroglycerin sl mg sl q5min prn chest pain omeprazole mg po daily prednisone mg po daily senna mg po bid prn constipation sertraline mg po daily triamcinolone acetonide ointment appl tp bid lesions triamterene hctz cap po daily albuterol sulfate mcg actuation inhalation q6h prn gabapentin mg po qid levothyroxine sodium mcg po every metformin xr glucophage xr mg po daily multivitamins tab po daily oxycodone immediate release mg po q8h prn breakthrough pain travatan z travoprost ophthalmic eye qhs discharge medications bisacodyl mg pr once duration dose ciprofloxacin hcl mg po q12h polyethylene glycol g po bid ramelteon mg po qhs should be given minutes before bedtime acetaminophen mg po q4h prn pain mild albuterol sulfate mcg actuation inhalation q6h prn amlodipine mg po daily aspirin mg po daily atorvastatin mg po qpm docusate sodium mg po bid gabapentin mg po qid levothyroxine sodium mcg po every losartan potassium mg po daily metformin xr glucophage xr mg po daily methadone mg po q8h prn severe back pain multivitamins tab po daily nabumetone mg po bid nitroglycerin sl mg sl q5min prn chest pain omeprazole mg po daily oxycodone immediate release mg po q8h prn breakthrough pain prednisone mg po daily senna mg po bid prn constipation sertraline mg po daily travatan z travoprost ophthalmic eye qhs triamcinolone acetonide ointment appl tp bid lesions triamterene hctz cap po daily discharge disposition extended care facility discharge diagnosis uti 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 you were hospitalized for a very severe infection now that you are stable you are able to leave and be discharged to rehab please be sure to follow up with your appointments listed below we wish you the best with your health warm regards health followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies penicillins nutrasweet aspartame sulfa sulfonamide antibiotics attending chief complaint confusion major surgical or invasive procedure none history of present illness yo f w severe ra w leukocytoclastic vasculitis venous insufficiency hypothyroid dm presenting with abdominal pain and ams per ems found seated hunched over on portable commode in bedroom of residence alert and oriented x4 with warm dry skin pt complained of constipation x2 days with associated abdominal pain family member reports pt had two bowel movements today but pt reports still feeling urgent need to go pt reports that she is very blocked up on our assessment patient intermittently reports abdominal pain also mentions a fall unsure when reports some mid back pain unable to obtain other significant history recent admission for fall thought to be due to deconditioned meds also hypothyroid restarted on levothyroxine d c to sar noted to have difficulty with med compliance ems physical l sided tenderness in luq on palpation no distention rigidity or masses felt pt had multiple large bruises all over her body which family member and pt report are from repeated falls in residence pt denied chest pain shortness of breath nausea vomiting fever or chills pt was extricated via stair chair secured to stretcher and transported to bid with no further change in condition in the ed on ems arrival the patient endorsed luq tenderness notably the patient recently had a admission for a fall due to suspected deconditioning the patient was noted to have difficulty with med compliance the patient reports bilateral pain denies fever chills dyspnea chest pain or n v initial vital signs were notable for ra exam notable for patient aaox2 trying to get out of bed perla eomi no obvious head trauma no c spine tenderness mild t spine tenderness flinches with abdominal palpation especially on the left side but is soft and not notably distended les with bilaterally venous stasis changes and multiple open wounds that do not appear actively infected labs were notable for ua large leuks protein wbcs studies performed include ct head no acute intracranial process diffuse hypodensities in the white matter again seen similar in extent to ct head dated and which could be related to prior therapy or due to extensive small vessel disease ct c spine no acute fracture or traumatic malalignment multilevel degenerative changes including mild anterolisthesis of c2 on c3 intervertebral disc space narrowing and osteophytosis worse at c4 c5 ct abd pelvis with contrast ground glass opacification in the posterior segment of the right upper lobe that may represent infection no intrathoracic or intra abdominal sequela of trauma irregularity and lucency at the superior endplate of l5 and inferior endplate of l4 are slightly progressed when compared to prior dated and infection cannot be excluded nonspecific unchanged prominent pelvic lymph nodes prominent bilateral external iliac lymph node are again seen measuring up to cm in short axis nonspecific mild stranding adjacent to the left adrenal may represent possible adrenal injury unchanged indeterminate renal lesion in the interpolar region of the right kidney seen since non emergent follow up renal ultrasound is recommended if no prior characterization has been performed pt was given olanzapine for agitation tylenol cefpodoxime 200mg ceftriaxone 1g azithro ivf sitter for agitation consults none vitals on transfer t102 bp hr90 rr20 ra upon arrival to the floor pt was somnolent and stated she had l sided pain of her torso her attention waxed waned and she responded somewhat appropriately when prodded vital signs were significant for hypertension and febrile to reduced to with iv tylenol her hcp her son was called for assessment of her baseline which he says is aox4 and occasionally combative she has a history of recurrent utis which present with similar delirium has mild baseline dementia with forgetfulness of certain memories but functional and independent otherwise past medical history chronic pain years back hands rheumatic fever rheumatoid arthritis htn hld type dm asthma cervical ca s p hysterectomy uterine ca hypothyroidism venous stasis depression anxiety htn hypothyroidism chronic venous stasis ulcers recurrent utis intermittent urinary retention chronic pain back injury nos asthma copd rheumatoid arthritis t2dm social history family history patient previously stated her family had medical conditions but she cannot describe more specifically physical exam admission physical exam vitals t102 bp171 hr90 rr20 ra general somnolent responds appropriately intermittently in mild distress abd pain heent ncat sclera anicteric and without injection cardiac regular rhythm normal rate audible s1 and s2 no murmurs rubs gallops lungs clear to auscultation bilaterally no wheezes rhonchi or rales no increased work of breathing back unable to evaluate for cva tenderness pt refusal abdomen soft non distended tender to palpation in left quadrants luq worse than llq healed surgical scar on r extremities b l erythema with multiple bruises and scars in various stages of healing with overlying blanching well demarcated erythema warm to touch l leg erythema outlined on pulses dp radial bilaterally skin see ext above warm neurologic sensation intact in discharge physical exam vitals po ra gen lying in bed on her left side eyes closed cv normal rate regular rhythm no m r g pulm ctab abdomen deferred due to abdominal pain ext b l with erythema with bruising and skin breakdown c w venous stasis changes neuro eomi r facial droop r upper extremity can elevate without resistance can move r toes and ankle improved from prior grossly normal on the left side pertinent results admission labs 31am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 31am blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 25am blood glucose urean creat na k cl hco3 angap 25am blood alt ast alkphos totbili 25am blood lipase 45am blood calcium phos mg 25am blood albumin 29am blood glucose lactate na k cl calhco3 interval labs 25am blood ptt 25am blood ret aut abs ret 30am blood lipase 00pm blood calcium phos mg cholest 25am blood caltibc vitb12 ferritn trf 00pm blood hba1c eag 00pm blood triglyc hdl chol hd ldlcalc 45am blood tsh 45am blood free t4 45am blood asa neg ethanol neg acetmnp neg tricycl neg discharge labs 43am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 43am blood glucose urean creat na k cl hco3 angap 30am blood glucose urean creat na k cl hco3 angap 43am blood calcium phos mg microbiology and urine cultures mixed bacterial flora colony types consistent with skin and or genital contamination urine culture no growth pm blood culture final report blood culture routine final staphylococcus coagulase negative isolated from only one set in the previous five days blood culture no growth blood culture x2 ngtd blood culture ngtd imaging ct c spine w o contrast study date of no acute fracture or traumatic malalignment multilevel degenerative changes including mild anterolisthesis of c2 on c3 intervertebral disc space narrowing and osteophytosis worse at c4 c5 multilevel posterior osteophytosis and calcified disc bulge result in moderate spinal canal narrowing most severe at c3 c4 multilevel uncovertebral facet joint hypertrophy resulting mild neural foraminal stenosis worse than right c3 c4 facet joint ct head w o contrast study date of no acute intracranial process diffuse hypodensities in the white matter again seen similar in extent to ct head dated and which could be related to prior therapy or due to extensive small vessel disease ct chest a p w contrast study date of nodular ground glass opacification in the posterior right upper lobe concerning for pneumonia in the setting of trauma underlying pulmonary contusion is not excluded mild stranding between the left adrenal gland and kidney is nonspecific but may relate to acute injury or ascending gu infection irregularity and lucency at the superior endplate of l5 and inferior endplate of l4 are slightly progressed when compared to prior dated and infection cannot be excluded nonspecific unchanged prominent pelvic lymph nodes ct abd pelvis with contrast study date of no etiology identified for severe abdominal pain specifically no intra abdominal abscess or small bowel obstruction the bladder wall appears mildly thickened which may be related to nondistention however cystitis should be considered and correlation with urinalysis is recommended redemonstration of the irregularity and lucency at the superior endplate of l5 in the inferior endplate of l4 which is unchanged compared to but slightly progressed compared to findings may represent progressive neuropathic degenerative changes however underlying infection cannot be excluded unchanged nonspecific prominent enlarged pelvic inguinal lymph nodes mr head w o contrast study date of late acute to subacute in the left corona radiata no intracranial hemorrhage atrophy and stable extensive white matter signal abnormality possibly related to prior therapy or chronic small vessel ischemic disease additional findings described above cta head and cta neck study date of redemonstration of a focus of late acute to subacute infarct in the left corona radiata no intracranial hemorrhage atrophy and stable extensive white matter disease possibly related to prior therapy or chronic small vessel ischemic disease no severe vascular stenosis occlusion or aneurysm mild atherosclerotic disease is noted in the posterior cerebral arteries and cavernous internal carotid arteries improved nodular and ground glass opacities in the posterior right upper lobe consistent with resolving infection or contusion additional findings as described above tte study date of impression mild symmetric left ventricular hypertophy with normal cavity sizes and regional global systolic function no definite structural cardiac source of embolism identified compared with the prior tte images not available for review of the findings are similar brief hospital course ms is a year old lady with history of rheumatoid arthritis on chronic prednisone leukocytoclastic vasculitis hypothyroidism diabetes and question of recent stroke with residual r sided weakness who presents with toxic metabolic encephalopathy in setting of pyelonephritis with mri confirming subacute left corona radiata cva pyelonephritis abdominal pain patient presented with fever to 7f and diffuse abdominal pain with pyuria on u a as well as cta p remarkable for stranding surrounding bladder and near l adrenal kidney which was repeated later in hospital course for ongoing abdominal pain and distension unrevealing for a new source of pain other sources of fever considered included possible pna given ground glass changes in rul seen on ct chest however patient without cough or hypoxia she completed day course of antibiotics with vancomycin ceftriaxone ending given history of mrsa uti at that time with indwelling foley cathether with resolution of fever urine cultures returned as mixed bacterial flora and blood cultures notable for only bottle in one set positive for coag negative staph after hours thought to be a contaminant given clinical stability patient did not receive stress dose steroids toxic metabolic encephalopathy delirium in ed patient was very agitated refusing care requiring multiple doses of im zyprexa then on medical floor was initially somnolent with negative cth by hospital day was ao x after treatment of infection as above throughout hospital course mental status waxed and waned likely with component of delirium but improved back to her baseline by discharge oriented and able to perform backwards as her antibiotics course was ending oxycodone methadone gabapentin were held in setting of altered mental status restarted methadone partway through hospital course held others to be restarted at rehab if needed right hemiparesis subacute l corona radiata stroke on hd1 patient noted to have r sided hemiparesis this was previously documented in pcp note from and upon further investigation appeared that patient had presented to in with complaint of right sided weakness per their discharge summary patient was not a candidate for intravenous alteplase mri mra of brain was ordered but patient was not cooperative we spoke again with her and family members and patient is insisting in refusing brain mri she was discharged with aspirin mg and lipitor mg daily their exam documents aox2 strength in lue in l leg and in r leg sensation in l arm dull when compared to right there was also report of patient saying this is not the first time she is having this right sided weakness and usually recovers after prolonged discussion mri was obtained showing late acute to subacute infarct in the left corona radiata no intracranial hemorrhage note was also made of extensive white matter signal abnormality likely related to chronic small vessel ischemic disease cta head and neck revealed no severe vascular stenosis occlusion or aneurysm tte with no definite structural cardiac source of embolism identified patient was initially maintained on telemetry without any report of atrial fibrillation but ultimately declined to continue monitoring long term event monitoring could be discussed as an outpatient regarding other stroke risk factors ldl was tsh ft4 a1c she was placed on aspirin mg atorvastatin mg and ot evaluated patient and recommended rehab and she was agreeable bcx for coag negative staph aerobic bottle from positive for coag negative staph bottles after hours of growth likely contaminant however patient did receive vancomycin x days given history of mrsa uti hypothyroidism note patient with tsh ft4 was evaluated by endocrine at and also seen for this at attributed to medication noncompliance started mcg daily weight based in which was continued this stay she will need repeat tsh within weeks hypertension continued amlodipine initially held triamterene hctz and losartan i s o normotension held on discharge for mild noted to have elevated creatinine from and bun from one day prior to discharge i s o receiving multiple contrast loads held antihypertensives as above chronic back and pain continued methadone mg tid prn confirmed with that patient takes methadone mg tid prn oxycodone mg tid oxycodone and gabapentin held as above please note that per last pain clinic note there may be an element of opioid induced hyperalgesia as well as opioid tolerance there was recommendation for continued gradual taper reduction starting with breakthrough oxycodone over intervals then methadone her narcotics contract from was reviewed dr with documentation of plan for taper by every weeks does not appear that this had been done benefit from new pain clinic referral chronic issues diabetes continued on ssi while in house resumed metformin on discharge rheumatoid arthritis with leukocytoclastic vasculitis continued prednisone 5mg daily urinary retention recurrent utis patient at baseline requires intermittent straight catheterizations due to intermittent trouble with initiating urinary stream previously referred to uro gyn by her pcp unclear if followed up required intermittent straight cath during hospitalization normocytic anemia mixed iron deficiency and anemia of chronic inflammation chronic venous stasis ulcerations care rn previously recommended waffle boots ace wraps to b l les transitional issues neurology follow up for cva started aspirin mg atorvastatin mg daily resumed levothyroxine mg daily held gabapentin and oxycodone for altered mental status consider pain clinic followup to taper off methadone held triamterene hctz and losartan for mild please restart in week if needed for bp control consider re referral to uro gyn for ongoing urinary retention monitor bms and uptitrate bowel regimen as needed continue to address long term event monitor as outpatient to workup stroke social work in contact with to increase patient s services which she adamantly refused would continue to readdress at rehab please recheck tsh tsh free t4 on noted on ct a p incidentally fusion of the l3 l4 vertebral bodies with irregularity and lucency of the superior endplate l5 and the inferior endplate l4 which is similar compared to prior but mildly progressed compared to unchanged nonspecific prominent enlarged pelvic inguinal lymph nodes further followup if clinically warranted code dnr dni molst in chart contact hcp noted in chart son greater than minutes was spent in care coordination and counseling on the day of discharge medications on admission the preadmission medication list is accurate and complete oxycodone immediate release mg po q12h methadone mg po q8h prn moderate pain gabapentin mg po qid senna mg po bid prn constipation first line triamterene hctz cap po daily sertraline mg po bid prednisone mg po daily nabumetone mg po bid metformin glucophage mg po daily losartan potassium mg po daily levothyroxine sodium mcg po 1x week amlodipine mg po daily omeprazole mg po daily atorvastatin mg po qpm aspirin mg po daily discharge medications acetaminophen mg po q6h prn pain mild docusate sodium mg po bid polyethylene glycol g po daily simethicone mg po qid dyspepsia gas atorvastatin mg po qpm levothyroxine sodium mcg po daily methadone mg po tid prn moderate severe pain rx methadone mg tab by mouth three times per day disp tablet refills senna mg po bid amlodipine mg po daily aspirin mg po daily metformin glucophage mg po daily omeprazole mg po daily prednisone mg po daily sertraline mg po daily held gabapentin mg po qid this medication was held do not restart gabapentin until there is need for it held losartan potassium mg po daily this medication was held do not restart losartan potassium until your kidneys recover and your blood pressure is higher held nabumetone mg po bid this medication was held do not restart nabumetone until you have more pain held oxycodone immediate release mg po q12h this medication was held do not restart oxycodone immediate release until your kidneys recover and your blood pressure is higher held triamterene hctz cap po daily this medication was held do not restart triamterene hctz until your kidneys recover and your blood pressure is higher discharge disposition extended care facility discharge diagnosis primary toxic metabolic encephalopathy sepsis urinary tract infection pyelonephritis right sided weakness late acute to subacute stroke in the left corona radiata abdominal pain constipation secondary hypertension hypothyroidism type diabetes rheumatoid arthritis with a history of leukocytoclastic vasculitis venous insufficiency discharge condition mental status clear and coherent level of consciousness alert and interactive activity status out of bed with assistance to chair or wheelchair discharge instructions dear it was a pleasure caring for you at why was i in the hospital you came to the hospital because of confusion and belly pain what happened to me in the hospital you got antibiotics for a urinary tract infection that went to your kidneys pyelonephritis you had pictures of your brain that confirmed you had a stroke which is the cause of the weakness on your right side you had pictures taken of your belly which did not show why you were having so much pain but restarting your methadone was helpful for your pain you were evaluated by our physical therapists who recommended that you go to rehab to get stronger before you go what should i do after i leave the hospital continue to take all your medicines and keep your appointments it is very important to participate in the rehab program so you can get as much of your strength back as possible before you go 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 penicillins nutrasweet aspartame sulfa sulfonamide antibiotics attending chief complaint abdominal pain major surgical or invasive procedure ct guided l4 l5 spine biopsy history of present illness ms is a year old female with medical history notable for stroke right sided weakness rheumatoid arthritis on prednisone leukocytoclastic vasculitis venous insufficiency and hypothyroidism who was recently admitted from for abdominal pain with course with concern for pylenephritis presented on from rehab with acute onset abdominal pain the patient reported diffuse abdominal pain that increases with food intake she reports a periumbilical pain similar to her last admission the pain is relieved by not eating she reports lb unintentional weight loss over the last month which concerns her she has her usual chronic back pain but this is no worse she denies any problems urinating or with her bowel movements specifically she denies black bloody bowel movements diarrhea or constipation point ros otherwise negative past medical history chronic pain years back hands rheumatic fever rheumatoid arthritis htn hld type dm asthma cervical ca s p hysterectomy uterine ca hypothyroidism venous stasis depression anxiety htn hypothyroidism chronic venous stasis ulcers recurrent utis intermittent urinary retention chronic pain back injury nos asthma copd rheumatoid arthritis t2dm social history family history patient previously stated her family had medical conditions but she cannot describe more specifically physical exam admission physical examination vitals ra general alert oriented sleepy but arousable intermittently groaning and grabbing her abdomen near her umbilicus heent mmm with upper dentures in place cv mild bradycardia no murmurs lungs clear anteriorly pt did not want to sit up for posterior lung exam abdomen soft moderate tenderness along periumbilicus and epigastrum voluntary guarding but no rebound no masses gu no foley ext warm well perfused pulses wrapped in clean dry guaze neuro aox3 mild right sided facial droop present on d c exam moving extremities with purpose decreased power in her right arm and leg back would not sit up for proper back exam discharge physical examination physical exam vitals gen older woman lying in bed asleep easily roused in nad heent nc at mmm neck supple heart rrr no m r g lungs ctab extr chronic skin changes on shins pitting edema ble neuro alert moving all extremities pertinent results admission labs 07am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 40am blood 07am blood glucose urean creat na k cl hco3 angap 07am blood alt ast alkphos totbili 07am blood lipase 40am blood totprot calcium phos mg 40am blood tsh 07am blood t3 free t4 40am blood crp antitpo less than 07am blood pep m spike no freekap freelam fr k l igg iga igm ife very faint relevant labs 07am blood lipase 10pm blood hscrp 20am blood tsh 10am blood tsh 40am blood tsh 20am blood t4 t3 calctbg tuptake t4index 10am blood t3 free t4 40am blood t3 free t4 07am blood t3 free t4 40am blood cortsol 30pm blood crp 10pm blood crp 40am blood crp antitpo less than 07am blood crp 40am blood pep no m spike freekap freelam fr k l igg iga igm ife faint free 07am blood pep m spike no freekap freelam fr k l igg iga igm ife very faint discharge labs not obtained imaging cxr no acute radiographic cardiopulmonary process ct abdomen with contrast endplate irregularity of l4 is similar to the most recent examination but mri of the lumbar spine must be performed to exclude osteomyelitis similar severe scoliosis of the lumbar spine secondary to l3 l4 and l4 l5 lateral subluxation similar severe lower lumbar spine degenerative disc disease and facet arthropathy micro blood culture routine final viridans streptococci isolated from only one set in the previous five days aerobic bottle gram stain final gram positive cocci in pairs and chains blood culture routine final no growth urine culture final no growth pm tissue source surgical vertebral intervertebral biopsy gram stain final per 1000x field polymorphonuclear leukocytes no microorganisms seen tissue final no growth anaerobic culture final no growth acid fast smear final no acid fast bacilli seen on direct smear acid fast culture pending fungal culture preliminary no fungus isolated brief hospital course assessment plan year old lady with complex medical history including chronic pain rheumatoid arthritis on prednisone leukocytoclastic vasculitis uterine cancer s p hysterectomy recent cva in recently admitted for abdominal pain concerning for pyelonephritis who represented with worsening of her periumbilical abdominal pain and back pain she was found to have an abnormal lucency on l4 l5 on ct scan with c f chronic osteomyelitis discitis vs severe degenerative joint disease she underwent spine biopsy of the lesion with cultures negative to date acute active problems back pain l4 l5 lesion due to complaints of back pain and abdominal pain as below patient underwent ct a p that noted a lucency on l4 l5 c f chronic discitis osteomyelitis vs severe djd this was in the setting of one positive blood culture with strep viridans mri was recommended for further evaluation however patient refused repeat blood cultures were all negative it is possible strep viridans could have represented contaminant however repeat crp obtained this admission elevated at wnl at presentation and also normalized later this admission without intervention id was consulted and recommended intervertebral disc biopsy and cultures we deferred mri based on id and radiology recommendations that a negative mri would not definitively rule out osteomyelitis would also show inflammation even if it were djd we proceeded with spine biopsy on with both the patient and the patient s hcp agreeing with the procedure the patient did not require chemical sedation prior to the procedure gram stain demonstrated polymorphonuclear cells cultures are negative though acid fast culture and fungal culture are still preliminary results patient was discharged afebrile and clinically stable to a rehabilitation facility with plan to follow up on final culture results id attending dr was aware of discharge plan and in agreement id has low suspicion for infection at this point and recommend no antibiotics plan is for ongoing monitoring of her symptoms and clinical status at rehab as an outpatient if there is any recurrent concern for infection fevers worsening symptoms persistently elevated crp etc she should be referred to see dr id fellow as an outpatient hypothyroidism patient exhibited symptoms of depression and withdrawal in the setting of hypothyroidism of note the patient is known to have hypothyroidism non compliant on levothyroxine last hospital admission tsh ft4 on this hospital admission tsh was initially found to be she was continued on mcg daily iv levothyroxine was considered however patient was unwilling to undergo piv placement and hcp was not established at that time on was and patient was continued on po regimen at mcg daily with endocrinology input she will need to follow up with endocrinology weeks after discharge for repeat tfts at that time abdominal pain patient complained of diffuse abdominal pain that increased with food intake and decreased when applying heat patient underwent ct a p in ed due to abdominal pain imaging noted possible lucency on l4 l5 c f discitis osteomyelitis see back pain gpc bacteremia above the patient refused mri and iv medications bowel regimen was initiated with patient demonstrating relief from abdominal pain after bowel movements abdominal pain was possibly related to constipation she did not have abdominal pain by discharge health care proxy hcp patient refusal of care the patient declined iv therapy during the majority of her hospitalization she also refused most blood tests the patient has one biological child and two step children and in was the health care proxy but was changed one month later to son was contacted but stated she did not wish to serve the role of hcp following meeting with we filed for hcp affirmation was established as hcp on and was kept informed of all medical decision making throughout the patient s hospitalization weight loss endorses unintentional weight loss per omr sheets her standard bed weight was lbs on and down to lbs on nutrition was consulted but it was felt that tube feeds would be unfeasible given patient s failure to comply with medical interventions and refusal to discuss nutritional intervention we encouraged po intake throughout the hospitalization provided a multivitamin with minerals and initiated mirtazapine to stimulate the patient s appetite she will need to follow up with her pcp outpatient regarding this weight loss chronic stable problems prediabetes hba1c on last admission patient s home metformin was held while inpatient and restarted for discharge hyperlipidemia history of cva patient was continued home atorvastatin and aspirin rheumatoid arthritis patient was continued on home prednisone mg daily home tylenol home methadone depression and anxiety patient was continued on home sertraline mg daily transitional issues outpatient endocrinology follow up in weeks post discharge is being arranged with md will need repeat tfts at that time endocrinology was notified of discharge and is working on an appointment please call endocrinology department if you do not hear back with an appointment time within the next days needs ongoing monitoring of her back pain and vitals at rehab as an outpatient if there is any recurrent concern for infection fevers worsening symptoms persistently elevated crp leukocytosis etc she should be referred to see dr id fellow as an outpatient follow up on finalized spine biopsy cultures fungal cultures and acid fast cultures were still preliminary negative at time of discharge needs at rehab to regain mobility strength after rehab discharge should f u with pcp regarding weight loss and consider referral to outpatient nutrition if patient amenable recheck labs including cbc and crp in weeks post discharge to assess if any ongoing c f infection upon discharge from rehab please write hcp son work letter to allow him to time off to care for the patient please give son of the hcp affirmation form and also the discharge summary which are being sent with the patient to rehab as son requested this code status dnr dni contact medications on admission the preadmission medication list is accurate and complete amlodipine mg po daily aspirin mg po daily atorvastatin mg po qpm levothyroxine sodium mcg po daily methadone mg po tid prn moderate severe pain omeprazole mg po daily prednisone mg po daily senna mg po bid sertraline mg po daily acetaminophen mg po q6h prn pain mild docusate sodium mg po bid polyethylene glycol g po daily simethicone mg po qid dyspepsia gas metformin glucophage mg po daily bisacodyl aily prn constipation first line methadone mg po daily discharge medications mirtazapine mg po daily multivitamins w minerals tab po daily mupirocin ointment appl tp tid levothyroxine sodium mcg po daily acetaminophen mg po q6h prn pain mild amlodipine mg po daily aspirin mg po daily atorvastatin mg po qpm bisacodyl aily prn constipation first line docusate sodium mg po bid metformin glucophage mg po daily methadone mg po tid prn moderate severe pain methadone mg po daily consider prescribing naloxone at discharge omeprazole mg po daily polyethylene glycol g po daily prednisone mg po daily senna mg po bid sertraline mg po daily simethicone mg po qid dyspepsia gas discharge disposition extended care facility discharge diagnosis primary diagnosis degenerative joint disease severe back pain secondary diagnosis hypothyroidism rheumatoid arthritis depression discharge condition mental status confused sometimes level of consciousness alert and interactive activity status out of bed with assistance to chair or wheelchair discharge instructions dear it was a pleasure to care for you at the why did you come to the hospital you came to the hospital because you experienced belly and back pains you also complained of poor appetite and weight loss what did you receive in the hospital you underwent ct imaging for your abdomen and back you were found to have a lesion in your lower spine you underwent a bone biopsy of the spine lesion biopsy showed no evidence of infection in the bone however we are awaiting final results and will inform you when they are available you were also found to have low levels of thyroid hormones you were seen by a specialized doctor in thyroid diseases endocrinologist the dose of thyroid hormone was set at mcg what should you do once you leave the hospital please work at rehab to regain your strength please take all your medication as advised please follow up with your doctors below we wish you the best your care team followup instructions

name unit no admission date discharge date date of birth sex f service neurosurgery allergies quinine attending chief complaint lumbar stenosis major surgical or invasive procedure l2 laminectomy history of present illness ms is a female who has a longstanding history of back pain the back pain is she is taking pain medication for the back pain she applies ice tried physical therapy and injection the back pain is constant sitting for more than minutes is difficult for her her back pain has no mechanical qualities she complains of severe leg pain the pain is this has a spasm like quality it is difficult for her to walk and it is worse with activity the pain is consistent with neurogenic claudication the patient denies any bowel or bladder symptoms the patient had extensive conservative therapy including medication and ice packs activity modification physical therapy and injections she is now s p l2 laminectomy past medical history chronic back pain s p multiple lumar surgeries urinary incontinence radicular ble pain hypothyroidism social history family history non contributory physical exam general awake and alert in no apparent distress cardiac regular rate and rhythm pulm breathing comfortably on room air gi soft non tender non distended neuro strength in bilateral upper and lower extremities sensation intact to light touch throughout pertinent results 37am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 37am blood glucose urean creat na k cl hco3 angap brief hospital course the patient was admitted to the neurosurgery service on and had a l2 laminectomy the patient tolerated the procedure well neuro post operatively the patient received oral pain medications with iv pain medications for breakthrough pain the patient s post op strength was maintained from prior to the operation and the patient denied any numbness or paresthesias after surgery cv the patient was stable from a cardiovascular standpoint vital signs were routinely monitored pulmonary the patient was stable from a pulmonary standpoint vital signs were routinely monitored gi gu post operatively the patient was given iv fluids until tolerating oral intake her diet was advanced when appropriate which was tolerated well she was also started on a bowel regimen to encourage bowel movement intake and output were closely monitored id post operatively the patient was started on iv cefazolin for three post op doses the patient s temperature was closely watched for signs of infection prophylaxis the patient received subcutaneous heparin during this stay and was encouraged to get up and ambulate as early as possible at the time of discharge the patient was doing well afebrile with stable vital signs tolerating a regular diet ambulating voiding without assistance and pain was well controlled discharge medications acetaminophen mg po q6h prn for fever or pain bisacodyl mg po pr daily constipation rx bisacodyl mg tablet s by mouth daily disp tablet refills diclofenac sodium mg po bid albuterol inhaler puff ih q4h prn sob diazepam mg po q8h prn muscle spasm docusate sodium mg po bid rx docusate sodium mg capsule s by mouth twice daily disp capsule refills imipramine mg po qhs levothyroxine sodium mcg po daily lidocaine patch ptch td daily prn pain metaxalone mg oral q8h multivitamins tab po daily oxybutynin mg po tid oxycodone immediate release mg po q4h prn pain rx oxycodone mg tablet s by mouth every hours disp tablet refills polyethylene glycol g po daily prn comstopation pregabalin mg po bid pregabalin mg po hs senna mg po qhs rx sennosides senna mg capsules by mouth at night disp capsule refills discharge disposition home discharge diagnosis lumbar stenosis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions surgery your dressing may come off on the second day after surgery your incision is closed with staples or sutures you will need suture staple removal please keep your incision dry until suture staple removal your incision is closed with dissolvable sutures underneath the skin and steri strips you do not need suture removal do not remove your steri strips let them fall off please keep your incision dry for hours after surgery do not apply any lotions or creams to the site please avoid swimming for two weeks after suture staple removal call your surgeon if there are any signs of infection like redness fever or drainage activity we recommend that you avoid heavy lifting running climbing or other strenuous exercise until your follow up appointment you make take leisurely walks and slowly increase your activity at your own pace try to do too much all at once no driving while taking any narcotic or sedating medication no contact sports until cleared by your neurosurgeon medications please do not take any blood thinning medication aspirin ibuprofen plavix coumadin until cleared by the neurosurgeon you may take ibuprofen motrin for pain you may use acetaminophen tylenol for minor discomfort if you are not otherwise restricted from taking this medication it is important to increase fluid intake while taking pain medications we also recommend a stool softener like colace pain medications can cause constipation when to call your doctor at for severe pain swelling redness or drainage from the incision site fever greater than degrees fahrenheit new weakness or changes in sensation in your arms or legs 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 back pain major surgical or invasive procedure rtx treatment plan to deliver gy in fractions total d1 completed history of present illness mr is a man s p l3 s1 lumbar decompression with duraplasty in and right hip replacement with epidural month ago who presents from with epidural abscess and osteomyelitis seen on mri transferred to for spine consult admitted to medicine for epidural abscess drainage with and treatment of osteomyelitis mr says he has had lower back and left hip pain since before his surgery but it has been getting worse since his r hip replacement month ago at which was performed with an epidural since then he has had worsening left sided hip and shooting leg pain over the last two weeks he has had poor po intake during this time due to pain but denies fever and chills he initially presented to one week ago where they did x rays and discharged him home over the weekend he had dark vomit and diarrhea today he presented to course vitals temp hr bp rr o2 sat ra exam was notable for normal sensation and motor function bilaterally though limited by pain mri spine lumbar w wo cont was most consistent with an epidural abscess and osteomyelitis destructive changes involving the l4 vertebral body and epidural collection abnormal enhancement pattern in the superior portion of the l5 vertebral body an abnormal enhancement in the paraspinal soft tissues epicentered at l4 extending superiorly to l3 on the left furthermore there are abnormal destructive areas in l1 l2 vertebral bodies and sacrum iv vanco 1g ceftriaxone 2g were given at he was transferred here for spine consult in the ed initial vitals were temp hr bp rr o2 sat ra exam was notable for sensation and motor function intact bilaterally in the lower extremities strength was limited due to pain rectal tone was normal and no saddle anesthesia noted labs notable for wbc hgb hct na cl bun k lactate imaging was notable for patient was given 1l ns 500ml 40meqk in ns 1mg iv hydromorphone spine was consulted and recommended inpatient guided biopsy upon arrival to the floor patient reports pain at rest which increases to with any movement he has been very limited with mobility due to pain and has not been ambulating due to pain currently using wheelchair to get around he also reports a 53lb weight loss over the last months he describes an esophageal burning that he contributes to not eating and vomiting he also reported that he has been using adult diapers due to one stool accident which he says was due to pain and being confined to the wheelchair so that he couldn t make it to the bathroom he is able to feel the need to move his bowels and is not generally incontinent the patient denies numbness paresthesias and fevers occasional chills at night for many years but no recently increased chills ros positive per hpi remaining point ros reviewed and negative past medical history bipolar disorder hypertension pre diabetes gerd patient reported hemochromatosis s p phlebotomy last done years ago social history family history aunt with hemochromatosis physical exam admission vital signs ra general alert and interactive in no acute distress heent has x cm round skin colored bumps on forehead c w epidermal cyst pupils equal round and reactive bilaterally extraocular muscles intact sclera anicteric and without injection moist mucous membranes oropharynx is clear cardiac regular rhythm normal rate audible s1 and s2 no murmurs rubs gallops lungs mild wheezes heard in the anterior lung fields bilaterally exam limited by pain abdomen normal bowels sounds non distended non tender extremities no peripheral edema skin no rashes appreciated neurologic cn2 intact strength in the upper extremities movement in lower extremities but exam limited by pain aaox2 discharge vitals tm bo hr rr spo2 on ra general lying in bed in no acute distress heent two 3x3cm palpable nodules on the left forehead with no overlying skin changes nodules are soft but not fluctuant non tender to palpation minimally mobile no central pore lungs clear to auscultation bilaterally cv regular rate and rhythm with normal s1 and s2 gi soft non distended non tender to palpation extremities warm and well perfused without edema neuro alert and interactive with strength dduction and abduction and elbow flexion and extension strength in the lower extremities bilaterally pertinent results admission labs 45pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 45pm neuts lymphs monos eos basos im absneut abslymp absmono abseos absbaso 45pm glucose urea n creat sodium potassium chloride total co2 anion gap 45pm calcium phosphate magnesium 45pm crp 26pm lactate k 21pm urine blood neg nitrite neg protein tr glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg 21pm urine rbc wbc bacteria few yeast none epi renal epi imaging head ultrasound palpable masses in the left lateral forehead correspond to vascular soft tissue masses which appear to have eroded the cortex of the underlying frontal bone and are continuous with the medullary cavity these are highly concerning for bone metastases alternative consideration includes multiple myeloma or lymphoma liver ultrasound diffuse heterogeneity of the left lobe of the liver with moderate intrahepatic biliary duct dilatation in the left lobe a discrete mass in the left lobe measures x x cm note is also made of an ill defined hypoechoic lesion in periphery of segment measuring up to cm these findings are concerning for either primary liver malignancy specifically cholangiocarcinoma or metastatic disease ct head incidental note made of a x mm right distal m1 segment mca aneurysm subtle hypodensity in the right frontal white matter in the centrum semiovale this is nonspecific however given likely malignancy mr head is recommended for further evaluation lytic and soft tissue lesions centered in the left frontal calvarium extending into the overlying scalp soft tissues with lytic involvement of the inner table no definite intracranial extension although evaluation is limited due to recent venous administration of iv contrast no evidence of intracranial hemorrhage acute infarction or mass effect ct chest left lung pulmonary nodules measure up to mm follow up as per clinical protocol is recommended diffuse esophageal wall thickening as well as enteric contrast material within it likely reflecting chronic reflux small right pleural effusion healing left posterolateral through tenth rib fractures ct abdomen pelvis enlargement of the caudate and left lobe with calcifications involving the anterior surface of the right lobe which appears smaller has there been prior hepatic resection alternatively this could represent cirrhosis multiple hepatic masses with large hypovascular lesion proximally in the left lobe showing delayed enhancement with associated left intrahepatic biliary dilatation is suspicious for a cholangiocarcinoma small arterially enhancing mass showing washout is suspicious for small hcc large heterogeneously enhancing mass in the left lobe is difficult to be characterized tissue sampling is recommended no evidence of portal vein thrombosis large non fat containing left adrenal mass is suspicious for a metastasis small subcentimeter arterially hyperenhancing lesion in the right adrenal gland is indeterminate in etiology multiple prominent gastrohepatic celiac periportal and portacaval lymph nodes large destructive mass involving l4 vertebral body with enhancing epidural component encroaching onto the spinal canal mri mra brain two left frontal calvarial lesions erode both the inner and outer table no evidence of intracranial extension lesions could be due to bony metastatic disease unless proven otherwise no evidence of intracranial metastatic disease approximately cm right centrum semiovale acute or subacute infarct bilateral m1 segment mca aneurysms measuring up to x mm on the right and x mm on the left narrowing of the cervical spine at c3 level partially visualized on sagittal t1 images this can be further evaluated with cervical spine mri cta head lobulated right mca bifurcation aneurysm with dominant components which overall measures x x mm x mm posteriorly projecting right ica terminus aneurysm x mm laterally projecting left mca bifurcation aneurysm calcified plaque mildly narrows the proximal v4 segment of the right vertebral artery calcified plaque mildly narrows the petrous segment of the right internal carotid artery again seen are two left frontal coronal vary expansile erosive masses with soft tissue component extending into the scalp suggesting metastases partially visualized expansile erosive mass centered in the right lateral mass and right vertebral body of c2 extending into the prevertebral space and also extending into the spinal canal with mild to moderate narrowing of the thecal sac the mass extends into the right c2 c3 neural foramen and into the right c2 transverse foramen encasing the distal right vertebral artery without evidence for narrowing dynamic lspine xr unchanged appearances of the known fracture at l4 no evidence of dynamic instability mr spine w wo contrast enhancing large soft tissue mass centered about right lateral and posterior elements c2 on c3 with vertebral body involvement at both levels epidural tumor extension at c2 c3 levels additional lesion at t findings consistent with metastases or lymphoma severe central canal narrowing at c3 level with cord flattening equivocal cord edema degenerative changes remainder of the cervical spine as above multilevel severe foraminal narrowing severe compression c3 vertebral body tte good image quality small pfo by saline contrast injection with maneuvers normal biventricular wall thicknesses cavity sizes and regional global systolic function bilateral lower extremity ultrasound impression no evidence of deep venous thrombosis in the right or left lower extremity veins pathology pathologic diagnosis skull lesion biopsy metastatic hepatocellular carcinoma see note note the tumor cells stain positively for glypican glutamine synthetase canalicular pattern positivity for polyclonal cea and cd10 and negative for ck20 and ck7 a reticulin stain highlights expansion of the cell plate the case was reviewed with dr discharge labs 45pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 45pm blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 48am blood ptt 45pm blood glucose urean creat na k cl hco3 angap 45pm blood calcium phos mg 45pm blood crp 45pm blood crp 21pm urine hours random 21pm urine uhold hold 21pm urine uhold hold 50am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 50am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 50am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 21pm urine hours random 21pm urine uhold hold 21pm urine uhold hold 21pm urine hyaline 21pm urine mucous rare 45pm crp brief hospital course with recent pound weight loss increased gerd symptoms and severe back pain was transferred from with initial concern for epidural abscess found to have metastatic hcc with multiple metastasis including spinal and skull metastasis subacute cva bilateral mca aneurysms and c2 mass with cord impingement started course of palliative radiation treatment to c2 c3 mass he will continue these as outpatient med oncology scheduled an outpatient appointment for follow up to discuss prognosis and treatment options metastatic hepatocellular carcinoma given his recent weight loss rapid growth of forehead lesions worsening gerd symptoms and unexplained transaminase elevation he received ultrasound of his forehead nodules and liver the subcutaneous nodules invaded bone and were concerning for metastasis liver ultrasound and subsequent staging ct have found both a small and a large mass ct abdomen pelvis also found an adrenal mass ct chest showed small lung nodules his back pain and lumbar mri findings are likely due to bone metastasis rather than osteomyelitis and he has continued to remain clinically stable and afebrile off antibiotics biopsy of his forehead mass was consistent with hepatocellular carcinoma oncology was consulted and recommended outpatient follow up he will follow up with dr on pain was controlled with 80mg oxycotin bid acetaminophen 1g po q8hr oxy 15mg po prn q4hrs gabapentin 600mg tid spinal metastasis c2 mass with cord impingement initial presentation of back pain and initial mri findings are likely due to bone metastasis rather than osteomyelitis cta on noted mass in c2 that could be concerning for spinal cord compression follow up c spine mri notable for enhancing large soft tissue mass centered about right lateral and posterior elements c2 on c3 with vertebral body involvement at both levels epidural tumor extension at c2 c3 levels additional lesion at t findings consistent with metastases or lymphoma severe central canal narrowing at c3 level with cord flattening equivocal cord edema radiation oncology was consulted and patient completed fractions of radiation therapy to prevent further spinal cord compression on mca aneurysm mra head on notable for bilateral m1 segment mca aneurysms measuring up to x mm on the right and x mm on the left cta notable for bilateral m1 segment aneurysms measuring up to cm on the right and cm on the left neurosurgery consulted and recommended blood pressure control and smoking cessation decision on intervention pending prognosis plan to follow up as an outpatient acute subacute neural infarct mri brain notable for approximately cm right centrum semiovale acute or subacute infarct noted to have r arm weakness compared to l arm now improving no other focal neurologic deficits neurology workup for possible etiology including hga1c tsh and tele monitoring for afib were all normal tte revealed a small pfo lenis were negative started on aspirin mg daily fasting lipids notable for ldl atorvastatin increased to 80mg per neurology recommendations will follow up with neurology as outpatient dyspepsia gerd his change in gerd symptoms and anorexia may be due to liver malignancy nutrition was consulted he was continued on home omeprazole 20mg and he will follow up with gi as outpatient for egd if within goals of care his symptoms were controlled on home omeprazole at time of discharge hip pain patient reported pain in his l hip which is s p replacement at worse with motion on exam he has tenderness with movement and log rolling of his left leg hip and femur x ray showed no effusion or erosions making septic arthritis or osteomyelitis less likely orthopedic surgery was consulted and they had low suspicion of septic joint revealed no dvt attributed to malignancy and pain was controlled with multimodal medications as in plan anemia microcytic anemia new from baseline in most likely mixed picture of chronic disease and iron deficiency given iron studies showing low normal iron normal ferritin and low transferrin and tibc it is likely related to his malignancy chronic issues htn hypertensive at and he was continued on home amlodipine atenolol and lisinopril amlodipine was held on discharge for low normal bp at rest and asymptomatic hypotension to sbp he will follow with pcp to consider further titration hld home atorvastatin dose was increased to 80mg pre diabetes self dc ed metformin hba1c insulin sliding scale while in hospital bipolar disorder mood stable on home lamotrigine transitional issues follow up with oncology on consider gi follow up and egd as an outpatient if within goals of care neurosurgery follow up for mca aneurysm dr neurology follow up for stroke neurosurgery follow up for consideration of surgical management of spinal metastases dr smoking cessation counseling hep b non immune is clinically stable for discharge today on the day of discharge greater than minutes were spent on the planning coordination and communication of the discharge plan medications on admission the preadmission medication list is accurate and complete lisinopril mg po daily lamotrigine mg po bid atenolol mg po daily amlodipine mg po daily atorvastatin mg po qpm multivitamins tab po daily omeprazole mg po daily hydrochlorothiazide mg po daily oxycodone immediate release mg po q6h prn pain moderate fish oil omega mg po bid discharge medications acetaminophen mg po q8h aspirin mg po daily docusate sodium mg po bid gabapentin mg po tid oxycodone sr oxycontin mg po q12h rx oxycodone oxycontin mg tablet s by mouth every twelve hours disp tablet refills senna mg po bid atorvastatin mg po qpm amlodipine mg po daily atenolol mg po daily fish oil omega mg po bid hydrochlorothiazide mg po daily lamotrigine mg po bid lisinopril mg po daily multivitamins tab po daily omeprazole mg po daily oxycodone immediate release mg po q6h prn pain moderate acetaminophen mg po q8h rx acetaminophen mg tablet s by mouth every eight hours disp tablet refills aspirin mg po daily rx aspirin mg tablet s by mouth once a day disp tablet refills docusate sodium mg po bid rx docusate sodium mg tablet s by mouth twice a day disp tablet refills gabapentin mg po tid rx gabapentin mg tablet s by mouth three times a day disp tablet refills oxycodone sr oxycontin mg po q12h rx oxycodone oxycontin mg tablet s by mouth every twelve hours disp tablet refills senna mg po bid rx sennosides senna mg tablet by mouth twice a day disp tablet refills atorvastatin mg po qpm rx atorvastatin mg tablet s by mouth at bedtime disp tablet refills atenolol mg po daily fish oil omega mg po bid hydrochlorothiazide mg po daily lamotrigine mg po bid lisinopril mg po daily multivitamins tab po daily omeprazole mg po daily oxycodone immediate release mg po q6h prn pain moderate rx oxycodone mg tablet s by mouth every six hours disp tablet refills held amlodipine mg po daily this medication was held do not restart amlodipine until your primary care doctor restarts it discharge disposition home with service facility discharge diagnosis metastatic hepatocellular carcinoma spinal metastasis mca aneurysms subacute stroke c2 mass with cord impingement 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 caring for you at why was i in the hospital you came to the hospital for back pain what happened to me in the hospital initially we thought your back pain was due to an infection in your back so you were treated with iv antibiotics you were found to have a new anemia low red blood cell count abnormal liver enzymes and nodules below the skin on your forehead we evaluated your liver and head and found lesions we were concerned were cancer that had spread from your liver we took images of your head and torso with a ct scanner and confirmed that the lesions likely represented cancer we also found another mass in your left adrenal gland and some lymph nodes in that area we then evaluated you with an mri of your brain which showed aneurysms outpouchings of your vessels you were seen by neurosurgery who did not recommend any urgent intervention but asked you to make an appointment in clinic when you leave the hospital a ct scan of your head also showed a mass on your spine that was concerning for compression of your spinal cord so the radidiation oncology team saw you and began radiation on those spinal masses to shrink them you were seen by the oncology team who made an appointment for you to see them when you leave the hospital to discuss prognosis and treatment options what should i do after i leave the hospital continue to take all your medicines and keep your appointments we wish you the best sincerely your team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies no known allergies adverse drug reactions attending chief complaint fatigue new effusion major surgical or invasive procedure bone marrow biopsy history of present illness pmh bipolar disorder htn metastatic hcc on nivolumab s p recent xrt to skull bony mets cva mca aneurysm presented to ed with fatigue and new pleural effusion as per call in patient initially presented to osh with increasing confusion cth with stable skull mets but further workup revealed neutropenia and cxr with new loculated pleural effusion accordingly he was given vanc cefepime and was transferred to for thoracic evaluation patient s wife is unavailable at time of admission to the oncology floor however patient was alert and oriented and able to provide adequate history he noted that he was not confused but instead was fatigued for days and that was the reason that his wife brought him to the outside hospital he noted that he was without fever chills cough sore throat nausea vomiting diarrhea abdominal pain dysuria rash sick contacts he noted that his oral intake has been less than optimal he noted that he has been voiding stooling without issue he denied any respiratory issues shortness of breath or labored breathing in the ed initial vitals ra wbc pmn bands hgb plt inr alt ast tbili ap alb phos na lactate ua glc prot bili but no e o infection ct chest revealed new lobulated right greater than left small pleural effusions no evidence of new or growing pulmonary nodules cirrhotic liver with multiple hepatic masses measuring up to cm compatible with known multifocal hepatocellular carcinoma not fully assessed on this study new wedge shaped hypodensity within the spleen which could be due to contrast bolus timing although a splenic infarct could have a similar appearance stable bilateral adrenal metastases no significant change in osseous metastatic disease of the ribs and vertebral bodies other findings as described above thoracic surgery consulted noted that they will followup ct results patient was given normal saline and admitted for further care 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 as per last clinic note by dr presented with back pain thought to be due to epidural abscess a complication of his recent spinal surgery found to have multiple spinal mets imaging shows multiple liver lesions and enlarged abdominal lymph nodes metastases of the spine skull l adrenal gland c2 paraspinal mass with cord impingement radiation therapy to c1 and associated paraspinal mass gy in fx plan port placement c1d1 folfox c2d1 folfox bolus d c for mouth sores c3d1 held for hypokalemia c3d1 folfox bolus d c zometa c4d1 folfox bolus d c d15 ci for mucositis zometa held for hypophos c5d1 folfox bolus d c ci for mucositis c5d15 folfox held for thrombocytopenia c6d1 folfox bolus d c ci oxali for thrombocytopenia zometa only phos improved c1 nivolumab past medical history bipolar disorder hypertension pre diabetes gerd patient reported hemochromatosis s p phlebotomy last done years ago s p l3 s1 lumbar decompression with duraplasty in s p right hip replacement in chronic neoplasm related pain mca aneurysm cva social history family history aunt with hemochromatosis physical exam admission physical exam vitals temp po bp hr rr o2 sat o2 delivery ra general chronically ill appearing man laying in bed appears comfortable no acute distress cachectic eyes pupils equally round and reactive to light anicteric sclera heent oropharynx clear dry mucous membranes neck supple normal range of motion lungs clear to auscultation bilaterally without any wheezes rales or rhonchi no increased respiratory rate speaks in full sentences cv regular rate and rhythm normal distal perfusion no edema abd soft nontender nondistended normoactive bowel sounds genitourinary no foley or suprapubic tenderness ext cachectic extremities decreased muscle bulk normal muscle tone skin warm dry no rash neuro alert and oriented x3 fluent speech able to describe his medical history in detail access port in right chest dressing clean dry intact discharge physical exam temp po bp hr rr o2 sat o2 delivery ra general very pleasant but cachectic man sitting up in bedside chair in no distress heent anicteric slcera perll op clear dry mm large 3cm circumscribed bony mass over left brow cardiac rrr normal s1 s2 no m r g lung appears in no respiratory distress crackles at bases bilaterally with good air movement speaking in full sentences abd soft non tender moderately distended and dull to percussion positive bowel sounds ext warm well perfused no lower extremity edema decreased muscle bulk neuro a ox3 good attention and linear thought strength full throughout sensation to light touch intact no asterixis skin no significant rashes access right chest wall port without erythema pertinent results admission labs 45pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 45pm blood neuts bands lymphs monos eos metas absneut abslymp absmono abseos absbaso 45pm blood ptt 45pm blood glucose urean creat na k cl hco3 angap 45pm blood alt ast alkphos totbili 45pm blood albumin calcium phos mg 55pm blood lactate discharge labs 12am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 16am blood neuts bands lymphs monos eos baso absneut abslymp absmono abseos absbaso 12am blood ret aut abs ret 12am blood glucose urean creat na k cl hco3 angap 16am blood alt ast ld ldh alkphos totbili 12am blood calcium phos mg microbiology blood culture x pending urine culture no growth bone marrow bx core biopsy pnd flow cytometry pnd cytogenetics pnd imaging hest w contrast new lobulated right greater than left small pleural effusions no evidence of new or growing pulmonary nodules cirrhotic liver with multiple hepatic masses measuring up to cm compatible with known multifocal hepatocellular carcinoma not fully assessed on this study new wedge shaped hypodensity within the spleen which could be due to contrast bolus timing although a splenic infarct could have a similar appearance stable bilateral adrenal metastases no significant change in osseous metastatic disease of the ribs and vertebrae imaging liver or gallbladder us cirrhotic liver with redemonstration of a large heterogeneous left hepatic mass additional masses are better appreciated on prior ct sequela of portal hypertension including mild splenomegaly and small to moderate volume ascites persistent moderate intrahepatic biliary ductal dilatation primarily in the left hepatic lobe similar to prior noevidence of common bile duct dilatation focal wedge shaped area of hypoechogenicity along the lateral margin of the spleen may represent a splenic infarct imaging mrcp mr abd probable progression of multifocal hcc compared to with increased number and size of multiple lesions although comparison is suboptimal due to differences in modality worsening tumor thrombus in left portal venous branches mild moderate intrahepatic biliary dilation in segments ii iii worse compared to no evidence of cholangitis or hepatic microabscess bilateral adrenal and multiple osseous metastases small bilateral pleural effusions appearing slightly loculated on the right brief hospital course principle reason for admission mr is a male with history of bipolar disorder hypertension cva mca aneurysm and metastatic hcc on nivolumab who presents with fatigue falls and new pleural effusion neutropenia resolved pure red cell aplasia thrombocytopenia he was found to have a hypoproliferative pancytopenia neutropenia for which he started neupogen on etiology was thought potentially immune mediated reaction to nivolumab and he underwent bm biopsy on with initiation of prednisone his wbc count improved but he continued to have a pure red cell aplasia per prelim bm bx results and his retic count remained low he received two tranfusions of prbc and we increased his steroids to 60mg bid should be monitored closely on follow up with extended prednisone taper we did start bactrim for pjp ppx but dc d on discharge given possible marrow suppressive side effects hyperbilirubinemia patient with stable ast alt but elevated tbili that rose on admission ruqus and mrcp showed stable persistent moderate intrahepatic biliary ductal dilatation and no obvious intervenable lesion now improved upon discharge we discontinued his statin fatigue fall ascites fatigue likely to dehydration malnutrition anemia medication effect no clear source of infection and neuro exam was normal generally improved and he was cleared for dc home with home we stopped his lisinopril and lorazepam pleural effusion new small lobulated right pleural effusion on imaging likely due to metastatic disease less likely infection given no symptoms per thoracic surgery very small effusion and given asymptomatic do not recommended drainage would need ct guidance if wish to drain we deferred concern for splenic infarct pvt ct was suggestive of infarct but could also have been contrast timing no role for a c for now given thrombocytopenia metastatic hcc secondary neoplasm of adrenal secondary neoplasm of bone rising afp and new effusion concern for disease progression despite initial treatment with folfox and single dose of nivolumab unfortunately unlikely he will be able to resume nivolumab will need to discuss further plans with his outpatient oncologist hyponatremia stable likely secondary to poor po intake at baseline as well as poor renal perfusion with ascites cancer related pain continued home oxycontin and oxycodone i refilled his rx on discharge continued bowel regimen hypophosphatemia repleted prn with oral repletion moderate protein calorie malnutrition nutrition consulted sent supplements history of cva held asa given thrombocytopenia held lipitor given transaminitis cont home atenolol hypertension continue home atenolol held home lisinorpil and monitor bps bipolar disorder continued home lamictal hypothyroidism continued home levothyroxine billing minutes spent coordinating this discharge plan transitional issues started prednisone 60mg bid consider non marrow suppressive pjp ppx stopped atorvastatin lisinopril and lorazepam holding asa due to thrombocytopenia please check cbc with reticu count on follow up consider outpatient paracentesis pending plt wbc stability will need prolonged steroid taper final bone marrow biopsy results medications on admission the preadmission medication list is accurate and complete oxycodone sr oxycontin mg po q8h atenolol mg po daily atorvastatin mg po qpm lamotrigine mg po bid lisinopril mg po daily multivitamins tab po daily omeprazole mg po daily docusate sodium mg po bid senna mg po bid aspirin mg po daily oxycodone immediate release mg po q4h prn pain moderate albuterol inhaler puff ih q6h prn shortness of breath wheezing levothyroxine sodium mcg po daily lorazepam mg po q8h prn nausea vomiting anxiety insomnia potassium chloride meq po bid prochlorperazine mg po q6h prn nausea vomiting calcium carbonate mg po bid vitamin d unit po daily magnesium oxide mg po daily lidocaine viscous ml po q3h prn throat pain phosphorus mg po daily maalox diphenhydramine lidocaine ml po qid prn mouth throain pain ondansetron mg po q8h prn nausea vomiting polyethylene glycol g po daily prn constipation discharge medications prednisone mg po bid rx prednisone mg tablet s by mouth twice a day disp tablet refills albuterol inhaler puff ih q6h prn shortness of breath wheezing atenolol mg po daily calcium carbonate mg po bid docusate sodium mg po bid lamotrigine mg po bid levothyroxine sodium mcg po daily magnesium oxide mg po daily multivitamins tab po daily omeprazole mg po daily ondansetron mg po q8h prn nausea vomiting oxycodone immediate release mg po q4h prn pain moderate rx oxycodone mg tablet s by mouth q4 hours disp tablet refills oxycodone sr oxycontin mg po q8h rx oxycodone mg tablet s by mouth q8 hours disp tablet refills phosphorus mg po daily polyethylene glycol g po daily prn constipation potassium chloride meq po bid prochlorperazine mg po q6h prn nausea vomiting senna mg po bid vitamin d unit po daily held aspirin mg po daily this medication was held do not restart aspirin until your platelet counts are better discharge disposition home with service facility discharge diagnosis immune mediated pan cytopenia hepatocellular cancer ascites pleural effusion discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear mr it was a pleasure taking care of you at you were admitted for weakness we found you had very low blood counts along with increasing fluid in your abdomen and a small amount around your lungs we believe you have had an immune reaction to your recent nivolumab immunotherapy causing damage to your bone marrow we gave you injections to help increase your white blood cell count started you on steroids and performed a bone marrow biopsy you also received two blood tranfusions we elected against interventions on the fluid in your belly or lung as you began to feel better you will need to follow up with dr closely to evaluate for recovery in your bone marrow and future treatment planning for your liver cancer sincerely your care team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies motrin lisinopril metformin amlodipine attending chief complaint fever major surgical or invasive procedure none history of present illness ms is a y o female with a past medical history of esrd on hd mwf dmii htn cad hbv hcv gerd gout and osteoporosis who present with fever cough and general malaise history was obtained via review of records and via phone interpreter majority of history was obtained from daughter patient was recently treated for a uti with po antibiotics and she has been doing well until yesterday when she developed general malaise fever nausea and lightheadedness also has been complaining of shortness of breath which has improved with albuterol inhalers this morning the patient had episodes of emesis as well as a productive cough today during hd she was found to have a fever to and leukocytosis and was transferred to for further evaluation in the ed initial vitals t bp hr rr ra labs were significant for wbc pmn hb plt na cr on hd gluc ap ast alt bnp ua wbc epi flu was negative bcx and ucx were drawn cxr showed no acute cardiopulmonary process and no consolidation patient received ceftriaxone g levofloxacin mg vanco mg vitals prior to transfer t hr bp rr ra upon arrival to the floor tc bp hr rr ra weight kg patient was resting in bed and in no acute distress reported that her breathing was uncomfortable but improved with inhalers also reported a heavy sensation on her chest which has persisted throughout the day states that she get dizzy when going from a sitting to a standing position ros reports fever at hd today no chills sob as stated above chronic cough no change no sick contacts no travel nausea vomiting no diarrhea mild lower extremity edema no rashes no recent dysuria however just finished treatment for a uti and had dysuria at the beginning of that course otherwise ros was negative unless stated above past medical history dmii esrd on hd mwf lue avg htn osteoarthritis osteoporosis hld asthma anemia hbv hcv gout gerd s p lap cholecystectomy in h o c diff social history family history she is widowed and she has children and in apparently good health physical exam admission physical exam vs tc bp hr rr ra weight kg gen alert lying flat in bed no acute distress oriented to self but not place or time heent sclera anicteric oropharynx mmm eomi neck supple without lad unable to visualize jvd pulm bibasilar crackles r l no wheezing cor rrr s1 s2 no m r g abd soft mildly distended no fluid wave normal bowel sounds extrem warm trace peripheral edema b l lue fistula with palpable thrill neuro cn grossly intact motor function grossly normal discharge physical exam vs tc tm bp hr rr ra weight kg bmx5 small soft stools finger stick 130s gen alert sitting up in bed no acute distress heent sclera anicteric oropharynx mmm eomi neck supple unable to visualize jvd pulm ctab no wheezing cor rrr normal s1 and s2 systolic murmur heard throughout abd soft mildly distended no fluid wave normal bowel sounds extrem warm trace peripheral edema b l lue fistula neuro cn grossly intact motor function grossly normal pertinent results admission labs 40am blood plt 40am blood 40am blood 40am blood 40am blood ctropnt 18pm blood ctropnt 40am blood ctropnt 40am blood 35am blood 08am blood 08am blood hcv discharge labs 00am blood plt 00am blood 00am blood imaging tte the left atrium and right atrium are normal in cavity size no atrial septal defect is seen by 2d or color doppler the estimated right atrial pressure is mmhg there is mild symmetric left ventricular hypertrophy with normal cavity size and regional global systolic function lvef tissue doppler imaging suggests an increased left ventricular filling pressure pcwp 18mmhg right ventricular chamber size and free wall motion are normal the diameters of aorta at the sinus ascending and arch levels are normal the aortic valve leaflets appear structurally normal with good leaflet excursion there is no aortic valve stenosis trace 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 mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function mild pulmonary artery systolic hypertension increased pcwp ruq us no evidence of focal hepatic lesions no ascites dilatation of the common bile duct is similar to prior and likely relates to state cxr no acute cardiopulmonary process no focal consolidation to suggest pneumonia micro am urine taken from final report urine culture final escherichia coli organisms ml enterococcus sp organisms ml sensitivities mic expressed in mcg ml escherichia coli enterococcus sp amikacin s ampicillin r s ampicillin sulbactam r cefazolin r cefepime s ceftazidime s ceftriaxone s ciprofloxacin r gentamicin r meropenem s nitrofurantoin s s piperacillin tazo s tetracycline r tobramycin i trimethoprim sulfa r vancomycin s am 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 am blood culture final report blood culture routine final no growth am blood culture final report blood culture routine final no growth brief hospital course ms is a y o female with a past medical history of esrd on hd mwf dmii htn cad hbv hcv gerd gout and osteoporosis who present with fever cough and general malaise found to have e coli uti hospital course was complicated by af with rvr hospital course is outlined below by problem e coli uti pt endorsed dysuria prior to presentation she was started on vanc cefepime empirically ucx grew e coli sensitive to ceftriaxone and her antibiotics were transitioned to ceftriaxone she received a day course of antibiotics her last day of antibiotics was af with rvr patient was found to have new afib with rvr during this hospitalization her af was controlled with av nodal agents tsh was wnl tte was performed and did not show valvular disease we discussed anticoagulation with the patient and her daughter we explained that there is a risk of stroke in the setting of af however given that the patient is a high fall and bleeding risk we wanted to discuss the risks benefits of anticoagulation with her outpatient provider her primary care doctor was called but was unreachable anticoagulation will be a transitional issue and should be discussed in the outpatient setting she remained on aspirin mg daily and metoprolol mg xl daily chest pain patient had chest pain on admission with negative troponins and ekg this was likely due to palpitations in the setting of af with rvr her pain improved with better hr control dyspnea patient complained of dyspnea on admission the patient had a difficult time explaining her symptoms but quickly resolved cxr did not show an acute process she remained on ra and received inhalers for asthma transaminitis alk phos elevation patient has known hcv and hbv but no diagnosis of cirrhosis ast alt and alk phos tb on admission a ruq us was performed and did not show evidence of cholangitis or hepatic lesions lfts were noted to downtrend diarrhea patient had diarrhea after receiving antibiotics there was concern for c diff initially and she was started on empiric treatment with flagyl her c diff returned negative however given that she had c diff in the past she received flagyl prophyalxis while on ceftriaxone her diarrhea was attributed to antibiotic associated diarrhea and received imodium prn hyponatremia patient s sodium was noted to decrease to this was attributed to low solute intake and she was encouraged to eat more during meals chronic issues gout continued allopurinol mg qod dm patient was placed on a sliding scale and required small amounts of humalog during her hospitalization it is unclear what she takes as an outpatient for her diabetes but possibly takes januvia this will need to be clarified htn continued metoprolol nifedipine esrd on hd continued dialysis patient will need to have hd on and the week of her regular hd schedule will resume the following week on gerd continued home ppi transitional issues patient is considered to be a high fall risk and the risk of starting anticoagulation may outweigh the benefit in the setting of af a discussion was held with her family about this issue the patient and family will need to discuss anticoagulation for afib with outpatient pcp discharged to rehab will need f u with outpatient pcp the week of patient will need hd on and her regular hd schedule will resume the following week on patient was kept on a ssi during this hospital stay with minimal insulin requirements it is unclear what medication she takes at home for her diabetes possibly januvia this will need to be clarified code status full contact daughter medications on admission the preadmission medication list may be inaccurate and requires futher investigation albuterol inhaler puff ih q6h prn shortness of breath allopurinol mg po every other day aspirin ec mg po daily docusate sodium mg po bid prn constipation diskus inh ih bid furosemide mg po bid losartan potassium mg po 4x week metoprolol succinate xl mg po daily montelukast mg po daily nephrocaps cap po daily nifedipine cr mg po daily omeprazole mg po bid tramadol ultram mg po bid prn pain vitamin d unit po daily calcium d calcium d3 mg 500mg unit oral bid fluticasone propionate nasal spry nu daily each nares nitroglycerin sl mg sl q5min prn chest pain alendronate sodium mg po qwed discharge medications allopurinol mg po every other day aspirin ec mg po daily docusate sodium mg po bid prn constipation fluticasone propionate nasal spry nu daily each nares diskus inh ih bid furosemide mg po bid losartan potassium mg po 4x week metoprolol succinate xl mg po daily montelukast mg po daily nephrocaps cap po daily nifedipine cr mg po daily nitroglycerin sl mg sl q5min prn chest pain omeprazole mg po bid tramadol ultram mg po bid prn pain vitamin d unit po daily calcium d calcium d3 mg 500mg unit oral bid alendronate sodium mg po qwed albuterol inhaler puff ih q6h prn shortness of breath insulin sc sliding scale fingerstick qachs insulin sc sliding scale using hum insulin discharge disposition extended care facility discharge diagnosis primary diagnosis urinary tract infection atrial fibrillation secondary diagnosis esrd hypertension dm diarrhea discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear ms you were admitted with a fever while you were here you received antibiotics and your symptoms improved you also received dialysis you were found to have an abnormal heart rhythm call atrial fibrillation we spoke to you about starting a blood thinner and you will need to continue having conversations with your primary care doctor you are being discharged to a rehab facility to get stronger before you go 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 motrin lisinopril metformin amlodipine attending chief complaint fever lethargy confusion major surgical or invasive procedure hemodialysis history of present illness this patient is a yo f with a hx of esrd on hd mwf dmii htn cad hbv hcv presenting with lethargy and fever following dialysis the patient s daughter noted that she was not as interactive when she was receiving dialysis yesterday and complaining of feeling hot she brought her into the ed where she was febrile to and found to have a wbc of lactate of and ua showing numerous wbcs ct head negative a trigger was called for unresponsiveness she responded well to empiric coverage with vanc cefepime flagyl the daughter mentioned that she has been getting utis frequently and her last one in was similar in presentation on transfer to the floor the patient was doing much better this morning she appeared of her baseline in terms of mental status as per her daughter s report currently she denies dysuria f c abdominal pain chest pain or leg pain past medical history dmii esrd on hd mwf lue avg htn osteoarthritis osteoporosis hld asthma anemia hbv hcv gout gerd s p lap cholecystectomy in h o c diff social history family history she is widowed and she has children and in apparently good health physical exam admission vitals ra general nad only alert oriented x knew name and but couldn t give date or year heent at nc eomi perrl anicteric sclera pink conjunctiva mmm neck nontender supple neck no lad no jvd cardiac rrr s1 s2 no murmurs gallops or rubs lung ctab no wheezes rales rhonchi breathing comfortably without use of accessory muscles abdomen nondistended bs nontender in all quadrants no rebound guarding no hepatosplenomegaly extremities no cyanosis clubbing or edema fistula at r forearm w dressing pulses dp pulses bilaterally neuro cn ii xii intact strength in all extremities skin warm and well perfused no excoriations or lesions no rashes discharge vitals 97ra general nad only alert heent anicteric sclera pink conjunctiva mmm neck nontender supple neck no lad no jvd cardiac rrr s1 s2 slight holosystolic murmur at the base lung ctab breathing comfortably without use of accessory muscles abdomen nondistended nontender in all quadrants no rebound guarding no hepatosplenomegaly extremities no cyanosis slight peripheral edema in fistula at l forearm pulses dp pulses bilaterally neuro cn ii xii grossly intact mildly weak in all extremities skin warm and well perfused no excoriations or lesions no rashes pertinent results cbc 19am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 20am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 22am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 11am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 37pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt bmp 19am blood glucose urean creat na k cl hco3 angap 20am blood glucose urean creat na k cl hco3 angap 30am blood glucose urean creat na k cl hco3 angap 22am blood glucose urean creat na k cl hco3 angap 11am blood glucose urean creat na k cl hco3 angap 37pm blood glucose urean creat na k cl hco3 angap lfts 30am blood alt ast alkphos totbili 11am blood alt ast alkphos totbili 37pm blood alt ast alkphos totbili lactate 39am blood lactate 58pm blood lactate urine 30pm urine color yellow appear hazy sp 00pm urine color yellow appear hazy sp 30pm urine blood sm nitrite neg protein glucose neg ketone neg bilirub neg urobiln neg ph leuks mod 00pm urine blood neg nitrite neg protein glucose neg ketone neg bilirub neg urobiln ph leuks lg 30pm urine rbc wbc bacteri few yeast none epi 00pm urine rbc wbc bacteri many yeast none epi 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 time taken not noted log in date time pm urine site not specified chem s ucu added final report urine culture final escherichia coli organisms ml sensitivities mic expressed in mcg ml escherichia coli amikacin s ampicillin r ampicillin sulbactam r cefazolin r cefepime s ceftazidime s ceftriaxone s ciprofloxacin r gentamicin r meropenem s nitrofurantoin s piperacillin tazo s tobramycin i trimethoprim sulfa r ct head impression no acute intracranial process lacunar infarct in the right pons additional chronic changes mri is more sensitive in detecting acute ischemia ruq us impression prominent extra hepatic bile duct measuring up to mm without intrahepatic dilatation this finding is stable since prior exam however if lfts suggest biliary obstruction further evaluation with mrcp could be obtained brief hospital course ms is a yo f with a hx of esrd on hd mwf dmii htn cad hbv hcv presenting with lethargy and fever following dialysis the patient s daughter noted that she was not as interactive when she was receiving dialysis on and complaining of feeling hot she brought her into the ed where she was febrile to and found to have a wbc of lactate of and ua showing numerous wbcs ct head negative a trigger was called for unresponsiveness in the ed she responded well to empiric coverage with vanc cefepime flagyl before transfer to the floor of note the daughter mentioned that she has been getting utis frequently and that her last one in was similar in presentation urinary tract infection ms was treated with iv ceftriaxone until her ucx speciation returned positive for multidrug resistant e coli her wbc continued to downtrend from the initial level of on admission she was switched to iv ceftazadime once her sensitivities returned and completed her treatment course on given her history of multiple utis recently it was suggested that her pcp consider imaging urogynocological evaluation or prophylactic abx moving forward transaminitis patient has a history of hcv hbv coinfection however it was thought that her initial transaminitis on admission alt ast was due to septic pathology possibly insufficient hepatic perfusion from hypotension during volume shifts during dialysis there was no evidence of cirrhosis or synthetic dysfunction ruq us with no change her lfts continued to downtrend throughout the admission elevated lactate she initially presented with an elevated lactate of likely caused by urosepsis vs hypotension in the setting of volume shifts during dialysis the lactate downtrended to by the first day of admission acute encephalopathy ms presented with altered mental status on admission likely secondary to toxic metabolic effects and had a negative head ct in the ed her mental status steadily improved with iv antibiotics and was close to baseline at the time of discharge dialysis ms received dialysis on her usual mwf schedule while admitted last dialysis session was chronic ms received her home medications for dm htn osteoporosis asthma and gout while admitted transitional issues f u with pcp within one week to discuss urogyn evaluation further imaging or prophylactic antibiotics to prevent future utis based on her prior speciation sensitivities however there may not be a good oral antibiotic for prophylaxis in her case discuss possible need for anticoagulation with pcp given diagnosis of atrial fibrillation with rvr diagnosed during admission never in afib during current admission discuss possible need to uptitrate antihypertensive medications systolic bps in the 140s 160s while admitted f u blood cultures to final result consider checking lfts at pcp appointment on new medications loperamide 2mg every hrs as needed for diarrhea changed medications none stopped medications none appointments pcp appointment on at 11am follow 2gm low salt diet 2g potassium code status full code hcp contact daughter to medications on admission the preadmission medication list is accurate and complete allopurinol mg po bid aspirin ec mg po daily fluticasone propionate nasal spry nu daily each nares fluticasone salmeterol diskus inh ih bid furosemide mg po bid losartan potassium mg po 4x week metoprolol succinate xl mg po daily montelukast mg po daily nifedipine cr mg po daily nitroglycerin sl mg sl q5min prn chest pain omeprazole mg po bid calcium d calcium carbonate vitamin d3 mg 500mg unit oral tid alendronate sodium mg po qwed albuterol inhaler puff ih q6h prn shortness of breath insulin sc sliding scale insulin sc sliding scale using hum insulin triphrocaps b complex with c folic acid mg oral daily vitamin d3 cholecalciferol vitamin d3 unit oral daily artificial tears drop both eyes bid prn dry eyes lidocaine ointment appl tp daily prn pain discharge medications albuterol inhaler puff ih q6h prn shortness of breath alendronate sodium mg po qwed allopurinol mg po bid artificial tears drop both eyes bid prn dry eyes aspirin ec mg po daily fluticasone propionate nasal spry nu daily each nares fluticasone salmeterol diskus inh ih bid furosemide mg po bid insulin sc sliding scale insulin sc sliding scale using hum insulin losartan potassium mg po 4x week metoprolol succinate xl mg po daily nifedipine cr mg po daily calcium d calcium carbonate vitamin d3 mg 500mg unit oral tid lidocaine ointment appl tp daily prn pain montelukast mg po daily nitroglycerin sl mg sl q5min prn chest pain omeprazole mg po bid triphrocaps b complex with c folic acid mg oral daily vitamin d3 cholecalciferol vitamin d3 unit oral daily loperamide mg po qid prn diarrhea rx loperamide anti diarrheal loperamide mg tablet by mouth four times a day disp tablet refills discharge disposition home discharge diagnosis primary diagnosis urinary tract infection transaminitis secondary diagnoses dmii esrd on hd mwf lue avg htn osteoporosis hld asthma anemia hbv hcv gout gerd discharge condition mental status confused sometimes level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms it was a pleasure taking care of you at the you were admitted to on because of lethargy confusion and fever after your dialysis session when you came to the hospital we found out that you had a urinary tract infection similar to ones you have had in the past this is likely what caused your symptoms after treating you with iv antibiotics your confusion and fever improved you finished your last dose of antibiotics on and won t require any antibiotics on discharge while here you also had some diarrhea this can often happen when on antibiotics we determined that it was not caused by a separate intestinal infection it should resolve over the next several days to prevent urinary tract infections it is important to practice good hygiene the most common source of bacteria is stool so ensuring that you clean well after stooling is important you should discuss with your pcp whether or not long term antibiotics to prevent infection is an option for you please continue to take all your medications as prescribed see below for a list of follow up appointments thank you for allowing us to participate in your care sincerely your medicine team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies motrin lisinopril metformin amlodipine attending chief complaint fever and confusion major surgical or invasive procedure none history of present illness ms is a year old woman with pmh significant for esrd on hd mwf dmii htn cad hbv hcv co infection and recent admission for e coli urosepsis presenting now with confusion and fever at dialysis the patient was undergoing scheduled hd when she developed fever and altered mental status and was referred to ed most recently she was admitted to for similar symptoms of lethargy and fever at which time she was found to have e coli uti in the ed she was febrile to with normal vitals labs were notable for a wbc lfts with alt ast and lactate ua with many bacteria though negative and nitrites in the ed she was given cefepime and vancomycin chest x ray and ct abdomen pelvis showed no process to explain fever leukocytosis on the floor vs ra the patient is well appearing report slightly running nose and shortness of breath consistent with baseline asthma but is otherwise without complaints this morning states feeling well denies dysuria though has had dysuria with previous utis denies feeling confused denies chills or fever still has runny nose and cough no other concerns past medical history dmii esrd on hd mwf lue avg htn osteoarthritis osteoporosis hld asthma anemia hbv hcv gout gerd s p lap cholecystectomy in h o c diff social history family history she is widowed and she has children and in apparently good health physical exam exam on admission vital signs afebrile tc bp hr rr ra general alert oriented in no acute distress heent sclera anicteric mmm jvp not elevated cv regular rate and rhythm normal s1 s2 systolic murmur no rubs or gallops lungs clear to auscultation bilaterally no wheezes rales rhonchi abdomen soft non tender non distended bowel sounds present gu no foley ext lue fistula with bruit present warm well perfused pulses no clubbing cyanosis or edema neuro alert and oriented to self and place states for date cnii xii grossly intact exam on discharge vital signs afebrile tc bp hr rr ra general alert oriented in no acute distress heent sclera anicteric mmm jvp not elevated cv regular rate and rhythm normal s1 s2 systolic murmur no rubs or gallops lungs clear to auscultation bilaterally no wheezes rales rhonchi abdomen soft non tender non distended bowel sounds present gu no foley ext lue fistula with bruit present warm well perfused pulses no clubbing cyanosis or edema neuro cnii xii grossly intact deltoids biceps triceps grip strength bilaterally pertinent results on admission 38pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 38pm blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 38pm blood ptt 38pm blood glucose urean creat na k cl hco3 angap 38pm blood alt ast alkphos totbili 38pm blood lipase 38pm blood albumin calcium phos mg 11pm blood lactate 15pm urine blood neg nitrite neg protein glucose ketone neg bilirub neg urobiln neg ph leuks neg 15pm urine rbc wbc bacteri many yeast none epi 15pm urine casthy notable labs 32am blood lactate blood culture routine x2 no growth blood culture routine pending urine culture final mixed bacterial flora colony types consistent with skin and or genital contamination imaging cxr no acute cardiopulmonary process ct a p w o con limited exam without intravenous or oral contrast equivocal peripancreatic fat stranding versus partial volume averaging and question of pancreatic calcification versus atherosclerotic calcification focal prominence of the main pancreatic duct versus side branch in the tail recommend correlation with pancreatic enzymes for pancreatitis and non emergent mrcp to further evaluate unchanged prominence of the cbd to mm which could be related to cholecystectomy this can be evaluated with the mrcp at the same time no diverticulosis mild lower lobe bronchiolar inflammation thickened left adrenal gland without discrete nodule ecg sr nani lvh peaked t waves stable from prior no ischemic changes labs on discharge 47am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 47am blood glucose urean creat na k cl hco3 angap 47am blood alt ast alkphos 10am blood calcium phos mg brief hospital course ms is a year old woman with pmh significant for esrd on hd mwf dmii htn cad hbv hcv co infection and recent admission for e coli urosepsis who presented with confusion and fever while at scheduled dialysis fever leukocytosis patient initially received cefepime infectious work up notable for negative urine culture negative chest x ray and blood cultures negative from remaining blood cultures are pending she denied any localizing symptoms including dysuria abdominal pain diarrhea she was empirically treated for uti with bacteria on ua see below she was afebrile during her admission and remained afebrile after discontinuing antibiotics uti she has a history of recurrent urinary tract infections with more than infections in the past year her daughter noted that she was on ciprofloxacin prior to admission however previous urine culture sensitivities showed resistance to ciprofloxacin she was empirically treated for uti with cefepime and discontinued when urine culture returned negative she had no fever during stay at ams a ox2 to self and place throughout the course of admission daughter who is her primary caretaker states that this is her baseline cough likely viral treated symptomatically elevated lfts downtrended throughout the course of admission on ct abdomen there was focal prominence of the main pancreatic duct versus side branch in the tail not likely pancreatitis with lipase within normal limits esrd on hd received dialysis according to her mwf schedule while inpatient chronic issues of t2dm osteoporosis asthma gout and gerd were all stable and continued with home medications family stated they would not want rehab or home she has hour supervision at home and therefore it was determined that she was safe for discharge home family also did not want transitional issues consider prophylactic antibiotics for recurrent uti consider outpatient urology for recurrent uti previous e coli culture and sensitivities showed ciprofloxacin resistance on ct focal prominence of the main pancreatic duct versus side branch in the tail and dilated common biliary duct consider non emergent mrcp to further evaluate daughter who is primary caretaker says she has some dementia at baseline baseline she is aao x new medications none patient had very well controlled bg while inpatient likely can d c insulin sliding scale as outpatient consider d c nifedipine given interaction with metoprolol medications on admission the preadmission medication list is accurate and complete albuterol inhaler puff ih q6h prn shortness of breath alendronate sodium mg po qwed allopurinol mg po bid artificial tears drop both eyes bid prn dry eyes aspirin ec mg po daily fluticasone propionate nasal spry nu daily each nares fluticasone salmeterol diskus inh ih bid furosemide mg po bid losartan potassium mg po 4x week metoprolol succinate xl mg po daily nifedipine cr mg po daily calcium d calcium carbonate vitamin d3 mg 500mg unit oral tid lidocaine ointment appl tp daily prn pain montelukast mg po daily nitroglycerin sl mg sl q5min prn chest pain omeprazole mg po bid triphrocaps b complex with c folic acid mg oral daily vitamin d3 cholecalciferol vitamin d3 unit oral daily loperamide mg po qid prn diarrhea insulin sc sliding scale insulin sc sliding scale using hum insulin discharge medications albuterol inhaler puff ih q6h prn shortness of breath alendronate sodium mg po qwed allopurinol mg po bid artificial tears drop both eyes bid prn dry eyes aspirin ec mg po daily fluticasone propionate nasal spry nu daily each nares fluticasone salmeterol diskus inh ih bid furosemide mg po bid insulin sc sliding scale insulin sc sliding scale using hum insulin lidocaine ointment appl tp daily prn pain losartan potassium mg po 4x week montelukast mg po daily nifedipine cr mg po daily omeprazole mg po bid calcium d calcium carbonate vitamin d3 mg 500mg unit oral tid loperamide mg po qid prn diarrhea metoprolol succinate xl mg po daily nitroglycerin sl mg sl q5min prn chest pain triphrocaps b complex with c folic acid mg oral daily vitamin d3 cholecalciferol vitamin d3 unit oral daily discharge disposition home discharge diagnosis fever uti discharge condition level of consciousness alert and interactive activity status ambulatory independent mental status confused sometimes discharge instructions dear ms it was a pleasure to take care of you at why was i here you had a fever and were confused when at dialysis what was done while i was here you were treated for a uti with antibiotics and it was stopped once bacteria was not found in your urine what should i do when i get home continue taking your medicines as prescribed you do not need to take the antibiotics ciprofloxacin prescribed by your primary care doctor on sincerely your team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies motrin lisinopril metformin amlodipine attending chief complaint head injury s p fall major surgical or invasive procedure eus with biopsy mediastinoscopy with biopsy history of present illness ms is a yo woman with pmh of esrd on hd mwf dmii htn cad hbv hcv co infection presenting after a fall history obtained via son and daughter at bedside as patient speaks only the patient reports that she got up to use commode bedroom today then slipped off of it she denies loc lightheadedness or weakness and states it was purely due to slipping she struck the bed and was reportedly down for minutes with moderate blood loss from a head wound the family put tobacco into the wound to try to stop the bleeding she denies fevers though she reports feeling cold this am she denies dysuria or changes urination aside from mildly reduced uop she has been eating and drinking normally she denies feeling confused she reports constipation over the last several hours but denies focal numbness tingling weakness she denies cough sob rhinorrhea she does note rare night sweats and lb weight loss over months she had some blood stool several days ago which self resolved without further issues she denies neck pain or any other pain elsewhere ed initial vitals ra imaging notable for ct torso with lad c f lymphoma and segmental colitis ct head without fracture or ich minimal anterolisthesis of c4 on c5 and c7 on t1 likely degenerative labs notable for wbc with pmn hgb most recent baseline trop negative x1 ua with wbc and many bacteria pos nit lactate na recent baseline cr baseline around bicarb with ag similar to recent values seen by spine who note minimal anterolisthesis of c4 c5 likely degenerative and recommend keeping hard c collar spine as well as nonemergent mri which can be performed inpt as pt is stable w a normal neuro exam received ctx 1g tdap x1 skin staples placed to close head wound vitals on transfer ra on arrival to floor patient denies complaints but requests water and to sit up bed if possible ros positive as per hpi all other systems reviewed and negative past medical history dmii esrd on hd mwf lue avg htn osteoarthritis osteoporosis hld asthma anemia hbv hcv gout gerd s p lap cholecystectomy h o c diff social history family history she is widowed and has children all apparently good health no notable family hx physical exam admission vs ra general well appearing elderly woman lying bed nad hard c collar place eyes perll eomi sclera anicteric hent semicircular wound on right anterior scalp with closed with staples c d i without notable erythema no bleeding mmm oropharynx clear without exudate or lesions respiratory ctab without crackles wheeze rhonchi on anterior exam limited by positioning with c collar cardiovascular rrr normal s1 and s2 no murmurs rubs or gallops gastrointestinal soft nondistended bs no masses or hsm mild suprapubic tenderness to palpation extremities warm and well perfused no peripheral edema skin warm no rashes no jaundice no skin ulcerations noted neurological alert and oriented x2 knows name at year but unsure of date cn2 intact strength ue and bilaterally follows commands appropriately discharge exam vitals po ra gen tired appearing initially sleeping on entry into the room seated upright bed breathing comfortably heent head laceration is well healed staples are removed eomi poor dentition with multiple fillings artificial teeth heart rr systolic murmur over r lusb no r g lungs clear to auscultation bilaterally no wheezing or rhonchi noted today abd soft nontender normoactive bowel sounds ext no edema wwp neuro awake alert conversant moving all extremities purposefully with normal strength no tremor or focal deficits appreciated skin there is some bruising at the clavicles at site of mediastinoscopy which is stable and some scattered bruising on her arms at phlebotomy sites pertinent results labs admission labs 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood glucose urean creat na k cl hco3 angap discharge labs 56am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 56am blood glucose urean creat na k cl hco3 angap 56am blood calcium phos mg micriobiology pm urine source final report urine culture final mixed bacterial flora colony types consistent with skin and or genital contamination blood culture x ngtd am sputum source induced acid fast smear final no acid fast bacilli seen on concentrated smear acid fast culture preliminary pending pm sputum source induced acid fast smear final no acid fast bacilli seen on concentrated smear acid fast culture preliminary mtb direct amplification preliminary m tuberculosis dna not detected by naat a negative naat cannot rule out tb or other mycobacterial infection naat results will be followed by confirmatory testing with conventional culture and dst methods this tb naat method has not been approved by fda for clinical diagnostic purposes however has established assay performance by validation accordance with standards performed at the result rec d by phone sample will be finalized upon receipt of written report am sputum site induced source induced gram stain final pmns and epithelial cells 100x field per 1000x field gram positive cocci pairs per 1000x field gram positive cocci clusters per 1000x field gram negative rod s quality of specimen cannot be assessed respiratory culture final moderate growth commensal respiratory flora acid fast smear final no acid fast bacilli seen on concentrated smear acid fast culture preliminary pending am rapid respiratory viral screen culture source nasopharyngeal swab final report respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at within week if additional testing is needed 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 influenza a and b negative rpr negative cryptococcal antigen negative am blood culture myco f lytic bottle blood fungal culture preliminary no fungus isolated blood afb culture preliminary no mycobacteria isolated blood culture x no growth final pm urine catheter final report urine culture final escherichia coli cfu ml sensitivities mic expressed mcg ml escherichia coli amikacin s ampicillin r ampicillin sulbactam r cefazolin r cefepime s ceftazidime s ceftriaxone s ciprofloxacin r gentamicin r meropenem s nitrofurantoin s piperacillin tazo s tobramycin i trimethoprim sulfa r imaging cxr findings trace pleural effusions mild left basilar opacity likely atelectasis the setting of shallow inspiration cxr impression comparison with the scout radiograph from the ct of there is little overall change prominence of these hilar and mediastinal regions are concerning for underlying malignancy following mediastinoscopy there is no evidence of pneumothorax or pneumomediastinum mri c spine w o con wetread again seen is minimal anterolisthesis of c4 on c5 and c7 on t1 likely degenerative there is no prevertebral edema or evidence of ligamentous injury there is no evidence of acute fracture cord signal is within normal limits again seen is moderate right neural foraminal stenosis due to a facet osteophyte small posterior intervertebral osteophytes at multiple levels but no high grade spinal canal stenosis ct torso w con no evidence of traumatic injury within the chest abdomen or pelvis numerous enlarged mediastinal lymph nodes with gastrohepatic and portacaval lymph node conglomerate measuring up to x cm with cystic components suspicious for malignancy although a definite primary is not visualized on this examination lymphoma is a consideration focal segment of proximal transverse colon demonstrating wall thickening and surrounding fat stranding which likely represents segmental colitis no nodularity to suggest an underlying primary malignancy grade anterolisthesis of l4 on l5 unchanged ct c spine without contrast minimal anterolisthesis of c4 on c5 and c7 on t1 likely degenerative nature however there are no priors for comparison no acute fractures moderate right neural foraminal stenosis at c4 ct head w o contrast skin staples overlying a small right frontoparietal scalp hematoma without evidence of underlying fracture or intracranial hemorrhage mri cervical spine grade spondylolisthesis without evidence of ligamentous injury mild multilevel degenerative changes of the cervical spine as detailed above no evidence of bony or ligamentous injury pathology final report specimen lymph node mediastinal 4r lymph node excision specimen lymph node mediastinal 4l lymph node excision diagnosis necrotizing granulomas see note diagnosis necrotizing granulomas see note note sections from part labeled as 4r lymph node compose of fragments of lymph nodes with extensive anthracotic pigment and focal granulomatous lesion sections from part labeled as 4l lymph node composed of fragments of lymphoid tissue with fibrosis and extensive necrosis special stains for infectious microorganisms afb gms and gram stain performed on both specimens and are negative the differential diagnosis includes infectious etiologies such as tuberculosis and non infectious causes such as necrotizing sarcoidosis which is a diagnosis of exclusion correlation with clinical findings and microbiology cultures is highlight recommended brief hospital course ms is a year old woman with past medical history of dementia diabetes type complicated by diabetic kidney disease esrd on hd hbv hcv co infection admitted following a fall with head laceration incidentally also reporting recent gi bleed with imaging concerning for malignancy fall head laceration cervical anterolisthesis per family patient presented following a mechanical fall with head strike and large forehead laceration with significant bleeding the ed laceration was stapled and hemostasis was obtained ct head and torso were reassuring that there was no serious traumatic injury imaging identified scalp hematoma ct and mri c spine showed mild anterolisthesis prompting spine service consult who felt she had no ligamentous injury and no acute surgical need they recommended soft c collar as needed with activity patient incidentally found to have several additional new medical issues listed below lymphadenopathy admission ct torso incidentally showed significant lymphadenopathy concerning for malignancy lymphoma oncology was consulted and recommended advanced endoscopy for eus and biopsy obtained eus with biopsy which was non diagnostic patient then underwent midastinoscopy with thoracic surgery on with lymph node biopsy final pathology consistent with necrotizing granulomas patient was r o for active tb with negative concentrated smears from induced sputa and negative naat rheumatology was consulted for concern for sarcoid but did not believe this was likely patient should id and clinic acute blood loss anemia gi bleed nos patient hgb nadired at from prior baseline of setting of above head wound with significant bleeding at family also reported recent isolated episode of blood patient s stool several days prior to presentation setting of ct scan with colonic thickening and enlarged lymph nodes as below there was concern for malignant cause of recent bleeding per discussion with oncology initially attempted to obtain eus as below colonoscopy to evaluate however patient was noncompliant with bowel preparation x successive nights despite counseling with family and interpreter discussed with family and team felt that acute benefit of colonoscopy was outweighed by risk of continued attempts at preparation when patient did not wish to bowel prep given that priority was to obtain lymph tissue without additional delay advanced endoscopy performed eus with biopsy as below there were no additional signs of gi bleeding and hgb remained stable consider outpatient colonoscopy should patient and family wish to pursue patient did require unit prbc transition while epo was held but epo was restarted once lymphoma was ruled out cough patient developed cough during hospitalization three induced sputa with concentrated smears were negative for tb naat testing was also negative sputum grew moderate commensal flora and multiple cxr were not consistent with pneumonia patient may have underlying non tuberculous mycobacteria she will f u with id as outpatient she was treated symptomatically with improvement of cough and did not receive any antibiotics latent tb patient s guantiferon gold was positive but as stated above active tb testing at time of discharge was negative treatment will be per id hypertension setting of acute bleed on presentation patient s antihypertensives were held once she was hemodynamically stable restarted nifedipine lasix metoprolol losartan of note patient s bp noted to be high the mornings prior to morning medication administration consider retiming medications to evening atrial fibrillation patient had episodes of non sustained afib with rvr while at dialysis setting of holding metoprolol these episodes were self limited and patient monitored on telemetry without any episodes of atrial fibrillation would consider outpatient holter monitor to evaluate for afib chads2 score of vasc of corresponding to a and risk of annual strokerespectively acute onset of afib with rapid resolution is likely triggered from recent events described above she has no prior history and is now sinus rhythm chest pain patient complaining of intermittent chest pain during hospitalization likely msk related setting of recent mediastinoscopy and pain exacerbated with coughing ekg without any evidence of ischemic changes urinary tract infection on admission patient found to have ua with bacteria and wbcs as well as leukocytosis although it was unclear if she had symptoms given her recent history of sepsis secondary to a uti risk of not treatment was felt to be high culture grew ecoli and patient completed days of iv ctx osteoporosis given patient esrd held alendronate could consider restarting at pcp esrd on hd continued lasix as above continued calcium vitd triphrocaps patient received dialysis during hospitalization for scheduling purposes but was transitioned back to dialysis prior to discharge next dialysis session should be diabetes type continued asa and insulin sliding scale she very rarely required any insulin for as bg was generally thus insulin was discontinued at discharge asthma continued albuterol dulera montelukast gerd continued ppi gout decreased dose of allopurinol given esrd minutes were spent on discharge planning and care coordination transitional issues patient should have id and rheumatology for continued workup of extensive lymphadenopathy pathology sample to be sent for molecular beacon testing by id no empiric treatment of tb recommended at this time insulin sliding scale discontinued as patient did not require insulin during hospitalization consider outpatient holder monitor to evaluate for paroxysmal atrial fibrillation as patient had limited episodes during hospitalization pending labs at discharge ace level c4 c4 vitamin d and rf medications on admission the preadmission medication list is accurate and complete albuterol inhaler puff ih q6h prn shortness of breath alendronate sodium mg po qwed allopurinol mg po daily artificial tears drop both eyes bid prn dry eyes aspirin ec mg po daily fluticasone propionate nasal spry nu daily each nares furosemide mg po bid lidocaine ointment appl tp daily prn pain losartan potassium mg po 4x week montelukast mg po daily nifedipine cr mg po daily omeprazole mg po bid calcium d calcium carbonate vitamin d3 mg 500mg unit oral tid loperamide mg po qid prn diarrhea metoprolol succinate xl mg po daily nitroglycerin sl mg sl q5min prn chest pain triphrocaps b complex with c folic acid mg oral daily vitamin d3 cholecalciferol vitamin d3 unit oral daily dulera mometasone formoterol mcg actuation inhalation bid insulin sc sliding scale insulin sc sliding scale using reg insulin triamcinolone acetonide cream appl tp bid prn pruritis discharge medications acetaminophen mg po q6h prn pain mild benzonatate mg po tid cepacol sore throat lozenge loz po q4h prn sore throat docusate sodium mg po bid guaifenesin ml po q6h polyethylene glycol g po daily prn constipation albuterol inhaler puff ih q6h prn shortness of breath alendronate sodium mg po qwed allopurinol mg po daily artificial tears drop both eyes bid prn dry eyes aspirin ec mg po daily calcium d calcium carbonate vitamin d3 mg 500mg unit oral tid dulera mometasone formoterol mcg actuation inhalation bid fluticasone propionate nasal spry nu daily each nares furosemide mg po bid lidocaine ointment appl tp daily prn pain loperamide mg po qid prn diarrhea losartan potassium mg po 4x week metoprolol succinate xl mg po daily montelukast mg po daily nifedipine cr mg po daily nitroglycerin sl mg sl q5min prn chest pain omeprazole mg po bid triamcinolone acetonide cream appl tp bid prn pruritis triphrocaps b complex with c folic acid mg oral daily vitamin d3 cholecalciferol vitamin d3 unit oral daily discharge disposition extended care facility discharge diagnosis lymphadenopathy latent tuberculosis colonic abnormality acute blood loss anemia fall with head trauma laceration hypertension urinary tract infection cervical anterolisthesis osteoporosis end stage renal disease diabetes type asthma gerd dementia high risk for delirium gout discharge condition mental status confused sometimes level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions ms it was a pleasure caring for you at you were admitted with a fall and a large cut on your forehead on a cat scan you were found to have enlarged lymph nodes your abdomen you underwent a biopsy that showed granulomas we performed multiple tests and determined you do not have cancer we are not sure what is causing these large lymph nodes it may due to tb an infection but testing is currently pending you should with the infectious disease and rheumatology doctors to determine what is causing your lymph nodes to be large you are now ready for discharge to rehab please take care your team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies motrin lisinopril metformin amlodipine attending complaint hypotension and altered mental status during dialysis major surgical or invasive procedure none history of present illness only history obtained from chart nephew niece over phone call and with the assistance of language line interpreter ms is a year old and speaking woman with a history of extrapulmonary tb lymphadenitis on ripe since uti treated on recent admission dm2 esrd on hd mwf chronic hbv hcv htn and cad who presented with confusion and transient hypotension sbps to during dialysis approximately one week prior to admission the patient s daughter noted foul smelling urine that was very dark in color and per the daughter the patient experienced some dysuria the patient endorsed feeling drunk at this time along with several episodes of vomiting though both resolved at the time of admission she also endorsed weakness at baseline she ambulates with the occasional assistance of a cane at home and she noted that she has had to use the cane in the days leading up to admission due to this weakness and shakiness in the legs per ed note the patient presented to her regular hemodialysis yesterday and was noted to have transient hypotension to the which corrected with administration of iv fluids she was then transferred to the ed notably per chart review she was recently hospitalized at the from to nd head strike with no traumatic injury identified on ct head but extrapulmonary tb found incidentally on ct torso after workup for lymphadenopathy three induced sputa with concentrated smears were negative for tb and naat testing was negative urinalysis and urine culture were positive for e coli on admission and she completed days of iv ceftriaxone she was discharged to rehab on and initiated ripe on she was discharged from on regarding her baseline status her niece last saw her at but spoke with a cousin who last saw her approximately days prior to admission she noted that the patient seemed well this week alert attentive and able to engage in conversation she did note that the patient does not leave the home very often and it is very possible she is not aware of the date at baseline notably the patient never learned how to read and has poor eyesight past medical history dmii esrd on hd mwf lue avg htn osteoarthritis osteoporosis hld asthma anemia hbv hcv gout gerd s p lap cholecystectomy in h o c diff social history family history she is widowed and has children all in apparently good health no notable family hx physical exam admission exam vital signs t bp hr rr o2 sat 99ra general alert oriented to person gives last name only place initially says home but acknowledges when prompted with hospital but not time no acute distress heent cutaneous horn noted below left eye sclerae anicteric mmm oropharynx clear eomi perrl neck supple jvp not elevated no lad cv regular rate and rhythm normal s1 s2 no murmurs rubs gallops lungs clear to auscultation bilaterally no wheezes rales rhonchi abdomen soft non tender non distended bowel sounds present no organomegaly no rebound or guarding gu no foley ext warm well perfused pulses no clubbing cyanosis or edema neuro cnii xii grossly intact discharge exam vitals t bp p rr o2 sat 96ra general alert oriented to person and place date no acute distress heent cutaneous horn noted below left eye sclerae anicteric mmm oropharynx clear eomi perrl neck supple jvp not elevated no lad cv regular rate and rhythm normal s1 s2 no murmurs rubs gallops lungs clear to auscultation bilaterally no wheezes rales rhonchi abdomen soft non tender non distended bowel sounds present no organomegaly no rebound or guarding gu no foley ext warm well perfused pulses no clubbing cyanosis or edema neuro cnii xii grossly intact pertinent results admission labs 20pm blood ctropnt 00am blood ctropnt 00am blood ctropnt 40pm blood ctropnt 50am blood ck mb 40pm blood ck mb 52pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 52pm blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 20pm blood glucose urean creat na k cl hco3 angap 40pm blood glucose urean creat na k cl hco3 angap 40pm blood calcium phos mg 20pm blood alt ast alkphos totbili 20pm blood albumin 20pm blood lipase 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 calcium phos mg 11am urine rbc wbc bacteri few yeast none epi 11am urine blood tr nitrite neg protein glucose neg ketone neg bilirub neg urobiln ph leuks neg 11am urine color yellow appear clear sp imaging studies pa lat chronic findings as noted above no evidence of mass hemorrhage or infarction chest abd pelvis w o no acute abnormality within the chest abdomen or pelvis stable lymphadenopathy of mediastinal and porta hepatis lymph nodes remains unclear in etiology head w o contrast chronic findings as noted above no evidence of mass hemorrhage or infarction brief hospital course speaking only with dm2 esrd on hd mwf chronic hcv hbv htn extrapulmonary tb lymphadenitis on ripe who presented from hd with hypotension and recent uti foul smelling urine recent uti started day course of ciprofloxacin by pcp for symptomatic complaints consistent with uti received dose of ceftriaxone in ed on to complete day course of antibiotics afebrile no chills or flank pain or cva tenderness not complaining of dysuria or other urinary symptoms urine was not foul smelling during admission u a was negative for leukocyte esterase and nitrites few bacteria wbc mg dl protein the proteinuria is her baseline notably she has had recurrent utis several of which were cipro resistant bacteria given entire picture decided to hold further antibiotics pt was discharged prior to urine culture resulting when culture finalized on patient and pcp were contacted to inform them that the urine culture was negative and no further intervention was required transient hypotension in dialysis elevated troponins no records from dialysis note indicates sbps to but unclear duration normotensive upon arrival to ed pt had troponin leak peak with subsequent downtrend w transient st segment depressions in v5 on initial ekg that resolved on subsequent ekgs pt denied cardiac or pulmonary complaints unclear whether hypotension preceded troponin leak or vice versa suspect that hypotension occurred in the setting of uti and poor po intake preceding hd session on which led her to become hypotensive while undergoing ultrafiltration troponin elevation was likely in the setting of demand ischemia which improved with resolution of hypotensive episode hypertension sbps in 170s 180s asymptomatic did not receive home anti hypertensives for hours in ed restarted on all home antihypertensives with improvement of bp to 160s altered mental status per son who lives with patient that patient was at her baseline mental status patient has a history of dementia noted during previous admission but further details are unclear and family does not seem to be aware alert and oriented to person and place and able to relate recent history clearly with no fluctuating consciousness ct head negative for acute changes demonstrates chronic atrophic changes and white matter hypodensities osteoporosis alendronate held at previous admission given esrd deferred to pcp restarting continued to hold alendronate during admission esrd on hd has hd on did not require dialysis while admitted continued calcium and vit d dm2 blood glucose at admission did not require insulin for glucose management during admission asthma continued albuterol montelukast given advair instead of dulera will restart dulera as outpatient gerd continued ppi gout continued allopurinol changed dosing to hd dosing mg after hd transitional issues x inpatient team will follow up the result of urine culture and contact one of the relatives niece for any interventions that need to take place pending the results of the culture this was completed prior to completion of this discharge summary culture was negative pt and pcp contacted no antibiotics required close follow up of blood pressure with primary care physician than minutes was spent on this patient s discharge day management medications on admission the preadmission medication list is accurate and complete albuterol inhaler puff ih q6h prn shortness of breath allopurinol mg po daily artificial tears drop both eyes bid prn dry eyes aspirin ec mg po daily fluticasone propionate nasal spry nu daily each nares furosemide mg po bid losartan potassium mg po 4x week metoprolol succinate xl mg po daily montelukast mg po daily nifedipine cr mg po daily omeprazole mg po bid acetaminophen mg po q6h prn pain mild benzonatate mg po tid cepacol sore throat lozenge loz po q4h prn sore throat docusate sodium mg po bid dulera mometasone formoterol mcg actuation inhalation bid alendronate sodium mg po qwed calcium d calcium carbonate vitamin d3 mg 500mg unit oral tid lidocaine ointment appl tp daily prn pain loperamide mg po qid prn diarrhea nitroglycerin sl mg sl q5min prn chest pain triamcinolone acetonide cream appl tp bid prn pruritis triphrocaps b complex with c folic acid mg oral daily vitamin d3 cholecalciferol vitamin d3 unit oral daily polyethylene glycol g po daily prn constipation guaifenesin ml po q6h rifampin mg po 3x week isoniazid mg po 3x week pyrazinamide mg po 3x week ethambutol hcl mg po 3x week pyridoxine mg po daily discharge medications allopurinol mg po 3x week acetaminophen mg po q6h prn pain mild albuterol inhaler puff ih q6h prn shortness of breath artificial tears drop both eyes bid prn dry eyes aspirin ec mg po daily calcium d calcium carbonate vitamin d3 mg 500mg unit oral tid docusate sodium mg po bid dulera mometasone formoterol mcg actuation inhalation bid ethambutol hcl mg po 3x week fluticasone propionate nasal spry nu daily each nares furosemide mg po bid isoniazid mg po 3x week lidocaine ointment appl tp daily prn pain loperamide mg po qid prn diarrhea losartan potassium mg po 4x week metoprolol succinate xl mg po daily montelukast mg po daily nifedipine cr mg po daily nitroglycerin sl mg sl q5min prn chest pain omeprazole mg po bid polyethylene glycol g po daily prn constipation pyrazinamide mg po 3x week pyridoxine mg po daily rifampin mg po 3x week triamcinolone acetonide cream appl tp bid prn pruritis triphrocaps b complex with c folic acid mg oral daily vitamin d3 cholecalciferol vitamin d3 unit oral daily held alendronate sodium mg po qwed this medication was held do not restart alendronate sodium until another physician tells you to start taking this again discharge disposition home discharge diagnosis primary diagnoses hypotension during hemodialysis demand ischemia secondary diagnoses end stage renal disease on hemodialysis hypertension diabetes asthma 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 from to why were you admitted to the hospital your blood pressure was quite low during dialysis there was concern that you were confused and may have a urinary tract infection uti what happened while you were in the hospital your blood pressure was monitored overnight it remained high instead of low we gave you all of your home medications to control your blood pressure we tested your urine it showed no signs of infection what will happen when you leave the hospital continue to take all of your medicines as prescribed we will follow the results of your urine study to ensure that no bacteria grow if any bacteria does grow and we need to treat you for a urinary tract infection we will call both you and your primary care doctor dr so we can prescribe you an antibiotic you should follow up with your primary care doctor dr some time this week to check in we wish you the best with your health going forward if you have any further questions regarding your care here please do not hesitate to contact us at front desk your medicine team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies motrin lisinopril metformin amlodipine attending chief complaint altered mental status major surgical or invasive procedure av fistula thrombectomy history of present illness ms is a y o speaking patient with pmh significant for alzheimer s dementia htn hld esrd on hd who originally presented to thrombectomy but was determined to not have capacity to consent to procedure and was unable to get consent from hcp thus was sent to the ed patient presented to the ed from after she was unable to provide consent for planned thrombectomy for clotted left fistula they attempted to contact the patient s healthcare proxy multiple times but were unable to reach her the ed was also unable to reach her in the ed the patient is mildly confused which appears to be her baseline she notes mild abdominal pain but no other symptoms in the ed initial vitals ra labs studies notable for cr k patient was given iv labetalol past medical history dmii esrd on hd lue avg htn osteoarthritis osteoporosis hld asthma anemia hbv hcv gout gerd s p lap cholecystectomy in h o c diff social history family history she is widowed and has children all in apparently good health no notable family hx physical exam admission physical exam temp po bp hr rr dyspnea rass pain score gen chronically ill appearing nad heent conjunctiva clear perrl mmm neck no jvd lungs ctab heart rrr nl s1 s2 no m r g abd mild epigastric tenderness normal bowel sounds extremities no edema wwp left av fistula skin no rashes neuro alert unable to establish orientation discharge physical exam hr data last updated temp tm bp hr rr o2 sat o2 delivery ra wt lb kg gen nad heent jaundice normocephalic atraumatic neck no jvd lungs ctab heart rrr nl s1 s2 no m r g abd normal bowel sounds extremities no edema wwp left av fistula with some bruising good thrill bruit skin no rashes neuro alert unable to establish orientation pertinent results pertinent results admission labs 20pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 20pm blood plt 20pm blood glucose urean creat na k cl hco3 angap relevant labs 29am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 08am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 34am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 03am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 31am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 00pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 05am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 25am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 05am blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 29am blood plt 37am blood plt 32am blood plt 34am blood plt smr very low plt ct 03am blood plt ct 31am blood plt ct 48am blood ptt 00pm blood plt ct 05am blood plt ct 25am blood plt ct 00am blood plt ct 48am blood 03am blood ret aut abs ret 31am blood ret aut abs ret 19pm blood hit ab neg hit 29am blood glucose urean creat na k cl hco3 angap 21pm blood glucose urean creat na k cl hco3 angap 32am blood glucose urean creat na k cl hco3 angap 03am blood glucose urean creat na k cl hco3 angap 25am blood glucose urean creat na k cl hco3 angap 00am blood glucose urean creat na k cl hco3 angap 34am blood alt ld ldh alkphos totbili 03am blood alt ast ld ldh alkphos totbili 29am blood calcium phos mg 21pm blood calcium phos mg 18am blood calcium phos mg 03am blood calcium phos mg 05am blood calcium phos mg 00am blood calcium phos mg 03am blood hapto 31am blood hapto 37am blood vitb12 08am blood vitb12 folate 29am blood hba1c eag 31am blood tsh 29am blood hbsag neg hbsab neg hbcab pos 00am blood igm hbc pnd 05am blood cmv igg pnd cmv igm pnd cmvi pnd ebv igg pnd ebna pnd ebv igm pnd ebvi pnd 00pm blood hcv vl not detect 05am blood hcv vl not detect 05am blood parvovirus b19 antibodies igg igm pnd microbiology pm blood culture source venipuncture blood culture routine pending no growth to date imaging imaging av fistulogram sch impression satisfactory restoration of flow following chemical and mechanical thrombolysis with a good angiographic and clinical result imaging art dup ext up uni or l impression small pseudoaneurysm immediately anterior to the av fistula in the left antecubital fossa discharge labs 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 00am blood plt ct 00am blood glucose urean creat na k cl hco3 angap 00am blood calcium phos mg brief hospital course ms is a y o speaking patient with pmh significant for alzheimer s dementia esrd and htn who presented for thrombectomy but was determined to not have capacity to consent to procedure and was unable to get consent thus admitted for procedure and dialysis on ms received a temp line and recieved hd given worsening of her condition eventually hcp was contacted and she had a avf thrombectomy on her course was complicated by pancytopenia requiring 1u prbcs with improvement in cell counts prior to discharge acute issues thrombosed fistula resolved patient was originally transferred from nursing home for intervention on clotted left av fistula she was unable to consent for the procedure and was admitted to medicine service she had a temporary hd line placed to get hd while awaiting consent from hcp consent was obtained and she underwent thrombectomy on she had hd successfully with her fistula after thrombectomy she had temporary hd line removed afterwards pancytopenia patient was noted to have new onset pancytopenia during her hospitalization etiology was unclear and felt to likely be related to either viral infection or dysplastic bone marrow hematology was consulted and assisted in infectious work up which was unremarkable at time of discharge work up was notable for negative hit antibodies mild evidence of hemolysis that improved normal bilirubin normal b12 and folate negative and hcv vl not detected pending work up included cmv igg ab cmv igm ab ebv ab panel hbc igm and parvovirus b19 antibodies hgb nadir was for which the patient received 1u of prbcs her discharge hgb was platelets nadir of with discharge platelet count of she required no platelet transfusions during her hospitalization patient should have repeat cbc at hd on could consider outpatient hematology follow up if pancytopenia does not improve esrd on mwf dialysis as noted above had temporary hd line placed for hd that was removed after fistula was fixed last hd session on will need hd on continue home calcium with meals sevelamer with meals htn patient was persistently hypertensive during her hospitalization her losartan was increased from non hd days to daily and she remained on her home metoprolol succinate could consider adding hydralazine as outpatient if bp remains elevated chronic stable issues dementia mental status was trended throughout her hospitalization and was felt to be at baseline copd hold home dulera nf duonebs q6hr prn continue home montelukast gerd continue ranitidine hx hep c s p treatment in code status dnr dni per molst on file transitional issues recheck cbc on with hd consider hematology follow up if persistently pancytopenic follow up infectious work up cmv igg ab cmv igm ab ebv ab panel hbc igm and parvovirus b19 antibodies consider addition of hydralazine if bp remains elevated discontinued aspirin for primary prevention consider a family meeting regarding proxy daughter hoping to transition hcp to son patient seen and examined on day of discharge stable for discharge to facility minutes on discharge activities medications on admission the preadmission medication list is accurate and complete ranitidine mg po daily aspirin mg po daily allopurinol mg po bid dulera mometasone formoterol mcg actuation inhalation bid loratadine mg po daily alendronate sodium mg po qfri losartan potassium mg po 4x week terazosin mg po qhs metoprolol succinate xl mg po daily montelukast mg po daily vitamin d unit po daily loperamide mg po qid prn diarrhea acetaminophen mg po q6h prn pain mild fever calcium acetate mg po tid w meals ferric citrate mg po tid w meals sevelamer carbonate mg po tid w meals discharge medications bisacodyl mg po daily prn constipation second line losartan potassium mg po daily acetaminophen mg po q6h prn pain mild fever alendronate sodium mg po qfri allopurinol mg po bid calcium acetate mg po tid w meals dulera mometasone formoterol mcg actuation inhalation bid ferric citrate mg po tid w meals administer with food separate administration of other medications by at least hours loperamide mg po qid prn diarrhea loratadine mg po daily metoprolol succinate xl mg po daily montelukast mg po daily ranitidine mg po daily sevelamer carbonate mg po tid w meals terazosin mg po qhs vitamin d unit po daily discharge disposition extended care facility discharge diagnosis thrombocytopenia thrombosed fistula discharge condition mental status confused always level of consciousness alert and interactive activity status out of bed with assistance to chair or wheelchair discharge instructions discharge instructions dear ms it was a privilege caring for you at why was i in the hospital you were in the hospital because you needed your fistula fixed what happened to me in the hospital you had your fistula fixed so you could get dialysis you had low red blood cell counts and platelets you were given one unit of red blood cells with improvement in your blood counts what should i do after i leave the hospital please continue to take all of your medications and follow up with your appointments as listed below 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 compazine doxycycline phenergan attending chief complaint n v eval cholelithiasis major surgical or invasive procedure egd history of present illness ms is a pleasant yo f with hld hypothyroidism htn n v abd pain since found to have biliary dilation and cbd stone admitted for ercp to eval for choledocholithiasis pt tells me that the abd pain has been intermittent at its worst however sometime she is without any pain at all no diarrhea constipation sob cp last episode of pain was in eus showed soft tissue mass in distal cbd within the ampulla mural nodule vs ampullary folds no stones were found brushings were taken the procedure was uncomplicated currently pt endorses nausea but is otherwise asx she tells me that just prior to coming into the hospital she was asx denies pain currently 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 diarrhea constipation no recent change in bowel or bladder habits no dysuria denies arthralgias or myalgias pt ros otherwise negative past medical history per chart confirmed with pt htn hld hypothyroidism cholecystecomy appendectomy hysterectomy social history family history per chart confirmed with pt htn in dad physical admission exam constitutional alert oriented no acute distress falling asleep during history exam eyes sclera anicteric eomi perrl enmt mmm oropharynx clear normal hearing normal nares neck supple jvp not elevated no lad cv irregular rate normal s1 s2 no murmurs rubs gallops respiratory clear to auscultation bilaterally no wheezes rales rhonchi gi soft non tender non distended bowel sounds present no organomegaly no rebound or guarding gu no foley ext warm well perfused no cce neuro aaox3 cnii xii and strength grossly intact skin no rashes or lesions discharge exam constitutional alert oriented no acute distress falling asleep during history exam eyes sclera anicteric eomi perrl enmt mmm oropharynx clear normal hearing normal nares neck supple jvp not elevated no lad cv irregular rate normal s1 s2 no murmurs rubs gallops respiratory clear to auscultation bilaterally no wheezes rales rhonchi gi soft non tender non distended bowel sounds present no organomegaly no rebound or guarding gu no foley ext warm well perfused no cce neuro aaox3 cnii xii and strength grossly intact skin no rashes or lesions pertinent results upper eus eus was performed using a linear echoendoscope at mhz frequency the head and uncinate pancreas were imaged from the duodenal bulb and the second third duodenum the body and tail were imaged from the gastric body and fundus pancreas parenchyma the pancreatic parenchyma was homogenous with a normal salt and pepper appearance pancreatic duct the pancreas was normal in size echotexture and contour no intra ductal stones were noted no dilated side branches were noted bile duct the bile duct was imaged at the level of the porta hepatis head of the pancreas and ampulla the cbd was dilated with a maximum diameter of mm no intrinsic stones or sludge were noted the bile duct and the pancreatic duct were imaged within the ampulla in the intra ampullary portion of the cbd a 5mm soft tissue lesion was seen differential diagnosis include ampullary fold vs malignant tumor ampulla the ampulla appeared normal both endoscopically and sonographically ercp w spincterotomy impression the scout film was normal the major papilla was normal the cbd was successfully cannulated using a clevercut sphincterotome preloaded with 025in guidewire contrast injection showed a dilated cbd but no filling defect a biliary sphincterotomy was successfully performed there was no post sphincterotomy bleeding the cbd was swep multiple times using a balloon small amount of sludge was successfully removed there was no protrusion of a tissue mass at the ampulla during the balloon sweeps a brushing was obtained from the distal cbd and sent for cytology there was excellent bile and contrast drainage at the end of the procedure the pd was not cannulated minimal injection was made i supervised the acquisition and interpretation of the fluoroscopic images the quality of the fluoroscopic images was good ekg sinus with pacs infrolateral q waves brief hospital course pleasant yo f with hld hypothyroidism htn n v abd pain since found to have biliary dilation and cbd stone admitted for ercp to eval for choledocholithiasis biliar dilation s p ercp no stone identified on egd however sludge present and was removed pt tolerated the procedure well with no abdominal pain post procedure post procedural lft s were downtrending and pt was tolerating a regular diet on discharge hyponatremia pt s na decreased from to with continuing ivf s possibly component of siadh given worsening with ivf s her home hctz was felt to also be contributing so was held on discharge until pt follows up with pcp abnl ekg sinus with pacs pt also noted to have q waves on ekg would recommend outpt risk stratification with stress test htn held hctz on discharge per above restarted home ace i amlodipine hld cont statin hypothyroidism cont levothyroxine medications on admission the preadmission medication list is accurate and complete amlodipine mg po daily atorvastatin mg po qpm enalapril maleate mg po daily hydrochlorothiazide mg po daily levothyroxine sodium mcg po daily ondansetron mg po frequency is unknown potassium chloride dose is unknown po frequency is unknown aspirin mg po daily vitamin d unit po frequency is unknown discharge medications ondansetron mg po q8h prn nausea potassium chloride meq po daily hold for k vitamin d unit po daily amlodipine mg po daily aspirin mg po daily atorvastatin mg po qpm enalapril maleate mg po daily levothyroxine sodium mcg po daily held hydrochlorothiazide mg po daily this medication was held do not restart hydrochlorothiazide until you speak with your pcp since your sodium was found to be low discharge disposition home discharge diagnosis biliary obstruction d t soft tissue mass in distal cbd mural nodule vs ampullary fold discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you came in with abdominal pain which was thought to be due to a stone in your bile duct you underwent a procedure called an ercp to relieve the obstruction and they found that there was a nodule or a fold of your bile outlet that was causing the obstruction a sample was taken for biopsy your abdominal pain improved post procedure please return if you have worsening abdominal pain nausea vomiting fevers chills or jaundice it was a pleasure taking care of you at followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies oxycodone attending major surgical or invasive procedure none attach pertinent results admission labs 22pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 22pm blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 22pm blood plt 22pm blood glucose urean creat na k cl hco3 angap 22pm blood ck cpk 01am blood alt ast alkphos totbili 22pm blood ctropnt 12am blood ck mb ctropnt 12am blood albumin calcium phos mg cholest 57am blood hba1c eag 12am blood hdl chol hd 01am blood cortsol 22pm blood tsh 22pm blood asa neg ethanol neg acetmnp neg tricycl neg discharge labs 10am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 10am blood plt 10am blood glucose urean creat na k cl hco3 angap 10am blood alt ast 10am blood calcium phos mg imaging cta head and neck impression head ct images degraded by motion artifact within this confine no definite acute territorial infarct intracranial hemorrhage mass or mass effect head cta patent circle of without evidence of stenosis occlusion or aneurysm mild atherosclerotic calcifications of the bilateral carotid siphons neck cta images degraded by motion artifact within these confines linear filling defect within the proximal right internal carotid artery is felt to reflect artifact related to patient motion there is approximately stenosis of the left proximal internal carotid artery by nascet criteria otherwise patent bilateral cervical carotid and vertebral arteries without evidence of stenosis occlusion or dissection carotid u s impression right ica stenosis left ica stenosis mri impression no acute intracranial abnormality no evidence of acute or subacute infarct mild nonspecific white matter signal changes most likely reflecting chronic small vessel disease in this age group brief hospital course is a female with a history of hypertension diabetes on insulin who presented as a transfer from with hypoglycemia secondary to overinsulinization found to have post hypoglycemic tonic clonic seizure complicated by paralysis with normal neurologic imaging and mental status returning back to baseline her insulin regimen was adjusted by the diabetes team with education provided by the diabetes educator transitional issues ensure follow up patient given contact information would benefit from dexcom glucose monitor neuro follow up with seizure clinics needs a basqimi intransal glucagon prescription upon follow up acute issues hypoglycemic seizure left common carotid artery calcification patient presented to with a tonic clonic seizure that was likely precipitated by a hypoglycemic episode with residual right sided hemiparesis secondary to a postictal state precipitated by an overly aggressive home insulin sliding scale work up for her seizure was unremarkable with no signs of infectious toxic or metabolic processes neurological imaging with an cta of the head and mri was also unremarkable she had no further episodes of seizures while she was admitted here she will need follow up in the seizure clinic for a routine outpatient sleep deprived extended eeg as an outpatient t2dm with repeated hypoglycemia her home insulin regimen consisted of units of lantus in the am followed by carb counting resulting in units of novolog which was an overly aggressive insulin regimen her a1c during this admission was she was evaluated by the team and transition to a simpler insulin regimen of lantus 35u qam with sliding scale humalog with meals she also met with the diabetes nurse educator for further education chronic issues hypothyroidism her tsh level was continued home levothyroxine 275mcg daily depression continued her home sertraline 100mg daily htn continued her home lisinopril hyperlipidemia continued her home simvastatin core measures code full confirmed contact husband medications on admission the preadmission medication list may be inaccurate and requires further investigation sertraline mg po daily simvastatin mg po qpm lisinopril mg po daily glargine units dinner insulin sc sliding scale using hum insulin levothyroxine sodium mcg po daily discharge medications baqsimi glucagon mg actuation nasal prn hypoglycemia rx glucagon baqsimi mg actuation spray nasal prn disp spray refills glargine units breakfast insulin sc sliding scale using hum insulin levothyroxine sodium mcg po daily lisinopril mg po daily sertraline mg po daily simvastatin mg po qpm discharge disposition home discharge diagnosis primary hypoglycemic seizure insulin depending diabetes mellitus secondary hypothyroidism depression hypertension hyperlipedmia discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms it was a pleasure caring for you during your admission to below you will find information regarding your stay why was i admitted to the hospital you were admitted to the hospital because you had a seizure due to low blood sugars what happened while i was in the hospital while you are in the hospital you received a number of imaging diagnostic test to evaluate for causes of your seizure these tests all came back normal additionally you also met with the diabetes doctors as as diabetes educator to work on a more stable insulin regimen what should i do when i go home take your medications as prescribed and attend your follow up appointments as scheduled please call on and request a hospital transition appointment within s a dietician appointment on the same day thank you for letting us be a part of your care your care team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies erythromycin base biaxin ciprofloxacin attending chief complaint left arm pain major surgical or invasive procedure coronary anatomy right dominant heart rotated to the left lm no significant disease lad proximal smooth disease mid vessel stenosis after large diag lcx luminal irregularities rca luminal irregularities ostial pda lesion interventional details we proceeded with pci of the mid lad xblad guide vessel wired with a runthrough wire angioplasty of the vessel followed by placement of a x mm xience des post dilated with a and nc balloon at high pressure timi iii flow residual impressions successful pci of severe mid lad stenosis with single des recommendations asa for life clopidogrel daily x months minimum history of present illness mr is a year old male with pmh notable for hiv on haart therapy t2iddm htn hld obesity ckd who presents with left arm pain he was in his usual state of health until when he was on the train when he noted severe dull left arm pain these symptoms lasted for approx minutes and improved over the next few hours he noted intermittent dull left arm pain that felt very similar to that same episode he then presented to his pcp who referred him to the ed trops negative nuclear stress test completed on showed reversible perfusion defect in the lad territory since being here he has had intermittent arm pain that can range in severity from a to an episodes of severe pain have been between to minutes he slept in a recliner last night as he feels his pain is less when sitting upright at baseline he is typically very sedentary as he had been unemployed for months in pt began a new job and has been walking approximately miles a day when he goes a certain distance he feels fatigued and short of breath which causes him to stop additionally when he goes up a flight a steps he feels very short of breath and can only do one flight at a time he denies a history of chest arm jaw or back pain lightheadedness dizziness pre syncope syncope worsening of his chronic edema orthopnea pnd or palpitations in the ed pt received crestor losartan fenofibrate haart therapy tylenol and insulin past medical history pmhx pshx hiv vl cd4 in on antiretroviral therapy prior hepatitis b status post septic shock requiring xigris with strep viridans bacteremia acute kidney injury and cvvh in the setting of severe sepsis chronic kidney disease stage iii history of splenic abscess status post splenectomy in secondary to salmonella abscess type diabetes mellitus on insulin morbid obesity hyperlipidemia asthma right medial meniscus tear history of severe bronchitis history of mrsa colonization social history family history nc physical exam physical exam gen alert no acute distress sitting comfortably in recliner neuro oriented x speech clear appropriate and comprehensible follows commands appropriately mae mood and affect appropriate cv regular rate rhythm chest lungs clear bilaterally diminished at bases breathing non labored abd soft non tender bs extr ble warm well perfused pulses skin warm and dry pertinent results 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 50pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 50pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 00am blood plt 00am blood ptt 39pm blood ptt 45pm blood ptt 50pm blood plt 00am blood glucose urean creat na k cl hco3 angap 50pm blood glucose urean creat na k cl hco3 angap 35am blood ctropnt 45pm blood ctropnt 00am blood ctropnt 50pm blood ctropnt 50pm blood probnp brief hospital course mr is a year old man with a pmh notable for hiv on haart therapy t2iddm hypertension hyperlipidemia obesity ckd who presented to the ed with left arm pain relieved with nitroglycerin he underwent a stress test which was notable for reversible ischemia in the lad territory he was started on heparin and nitro gtts pre cath and underwent a cardiac catheterization on and was found to have a severe mid lad stenosis and one des was placed via a right radial approach his access site is clean without bleeding or hematoma his csm is normal his left arm pain never resolved and continues despite coronary revascularization he will be referred to his pcp to have outpatient work up for other non cardiac cause he was started on asa plavix and increased his dose of crestor he will follow up with dr long term cardiology care medications on admission the preadmission medication list is accurate and complete losartan potassium mg po daily fish oil omega mg po bid fenofibrate mg po daily rilpivirine mg oral daily emtricitabine tenofovir truvada tab po q48h ritonavir mg po daily rosuvastatin calcium mg po qpm liraglutide mg ml mg ml subcutaneous daily glargine units breakfast multivitamins tab po daily albuterol sulfate mcg actuation inhalation q4h prn discharge medications aspirin mg po daily clopidogrel mg po daily darunavir mg po daily glargine units breakfast rosuvastatin calcium mg po qpm albuterol sulfate mcg actuation inhalation q4h prn emtricitabine tenofovir truvada tab po q48h fenofibrate mg po daily fish oil omega mg po bid liraglutide mg ml mg ml subcutaneous daily losartan potassium mg po daily multivitamins tab po daily rilpivirine mg oral daily ritonavir mg po daily discharge disposition home discharge diagnosis cad s p des to mid lad discharge condition mr is a year old man with a pmh notable for hiv on haart therapy t2iddm hypertension hyperlipidemia obesity ckd who presented to the ed with left arm pain relieved with nitroglycerin he underwent a stress test which was notable for reversible ischemia in the lad territory he was started on heparin and nitro gtts and which were stopped after his cardiac catheterization he is now s p cardiac catheterization and des to lad angina fairly constant left arm discomfort since arrival to on worst was currently states has not been since his arrival now s p cardiac catheterization with pci of severe mid lad stenosis with ntg gtt stopped post cath heparin gtt stopped post cath asa 81mg po daily lifelong start plavix 75mg daily x minimum months referral to cardiac rehab upon discharge follow up with dr for cardiologist per patient request dm continue lantus takes victoza at home may resume upon discharge non formulary here monitor iss prn carb consistent diet hypertension bp stable 120s 70s losartan held for cath cr now resume post discharge hyperlipidemia increase crestor to mg cont fenofibrate ckd stage iii gfr creat pre and post iv hydration holding losartan for procedure may resume upon discharge renal function labs on hiv cont home med regimen mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted to with left arm pain and were worked up for a cardiac source you had an abnormal stress test followed by a cardiac catheterization you were found to have a blockage in your left anterior descending artery and a drug coated stent was placed to improve blood flow to the heart you will take aspirin 81mg daily for life and plavix 75mg daily these will prevent a clot from forming in your stent do not stop taking either of these unless your cardiologist instructs you to do so stopping either of these will put you at risk for a life threatening heart attack we also recommend that you consider attending a cardiac rehab program a referral has been provided with your discharge paperwork care of your right wrist access site will be provided in your discharge instructions we are providing you with a lab slip to get your kidney function tests checked on we will request that the results be sent to your pcp your arm pain has not resolved despite your improved blood flow to the heart muscle we recommend that you follow up with your pcp to be worked up outpatient for other non cardiac related sources it has been a pleasure caring for you at followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies erythromycin base biaxin ciprofloxacin attending chief complaint pe major surgical or invasive procedure tee dccv history of present illness y o male with hx of hiv on haart therapy prostate cancer s p brachytherapy t2iddm htn hld obesity ckd presents w tachycardia and dyspnea on exertion patient went to pcp today for bilateral lower ext edema but was found to have a a heart rate of 130s so sent here he states that for the past few weeks he has had progressive dyspnea with exertion and b l swelling no history of blood clot no chest pain no fevers no abdominal pain n v cough or congestion has had increased erythema over the left lower ext medial mal with pain progressively worsening in the ed initial vitals were hr bp rr o2 exam notable for rle swelling erythema over bilat malls abrasions over the anterior shin full rom of all joint labs notable for agap repeat whole k probnp trop t lactate imaging was notable for cta pulmonary emboli extending from the distal right main pulmonary artery to segmental level in right upper and middle lobes and subsegmental level in right lower lobe no left sided pulmonary emboli difficult to exclude right heart strain echocardiogram would further assess no focal consolidation mild nodular contour of the liver raise concern for cirrhosis correlation with liver function test is recommended for further evaluation status post splenectomy on right there is non occlusive deep vein thrombus of a right posterior tibial vein patient was given iv piperacillin tazobactam ivf ns iv vancomycin 1500mg iv heparin unit ivf ns started upon arrival to the icu patient reports feeling fine without sx review of systems was negative except as detailed above past medical history pmhx pshx hiv vl cd4 in on antiretroviral therapy prior hepatitis b status post septic shock requiring xigris with strep viridans bacteremia acute kidney injury and cvvh in the setting of severe sepsis chronic kidney disease stage iii history of splenic abscess status post splenectomy in secondary to salmonella abscess type diabetes mellitus on insulin morbid obesity hyperlipidemia asthma right medial meniscus tear history of severe bronchitis history of mrsa colonization social history family history nc physical exam admission exam general well appearing sitting in bed with no distress heent ncat cardiac rrr no mgr pulmonary lungs clear to auscultation b l no wheezing chest no tenderness to palpation abdomen soft and non distended non tender to palpation extremities rle swelling erythema over bilat malleoli w abrasions over the anterior shin full rom of all joints skin abrasions over the anterior shin neuro a ox3 motor and sensory exam grossly normal discharge exam general well appearing male in no acute distress comfortable heent ncat eomi mmm cardiac rapid rate regular rhythm distant heart sounds no appreciable murmurs pulmonary clear to auscultation bilaterally breathing comfortably on nasal cannula abdomen soft non tender non distended no hepatosplenomegaly extremities warm well perfused on r l right leg with multiple healing ulcers diffuse erythema around right ankle tender warm no clear border between erythema and normal skin neuro aaox3 cnii xii grossly intact moving all four extremities with purpose pertinent results admission labs 32pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 32pm blood neuts lymphs monos eos baso nrbc im absneut abslymp absmono abseos absbaso 32pm blood ptt 32pm blood plt 32pm blood glucose urean creat na k cl hco3 angap 32pm blood alt ast alkphos totbili 32pm blood probnp 32pm blood ctropnt 32pm blood albumin calcium phos mg 58am blood psa 13pm blood temp po2 pco2 ph caltco2 base xs intubat not intuba 51pm blood lactate 00pm blood lmwh discharge labs 51am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 51am blood glucose urean creat na k cl hco3 angap 58am blood ast alkphos totbili 51am blood calcium phos mg pertinent studies tee there is no spontaneous echo contrast or thrombus in the body of the left atrium left atrial appendage the left atrial appendage ejection velocity is normal the interatrial septum is dynamic but not frankly aneurysmal there is no evidence for an atrial septal defect by 2d color doppler though evaluation was limited by tachycardia and limited images obtained overall left ventricular systolic function is at least mildly depressed with beat to beat variability in the left ventricular contractility due to the irregular rhythm the right ventricle has moderate global free wall hypokinesis there are simple atheroma in the descending aorta to from the incisors the aortic valve leaflets are mildly thickened no masses or vegetations are seen on the aortic valve no abscess is seen there is trace aortic regurgitation the mitral valve leaflets appear structurally normal with no mitral valve prolapse no masses or vegetations are seen on the mitral valve no abscess is seen there is mild to moderate mitral regurgitation the tricuspid valve leaflets appear structurally normal no mass vegetation are seen on the tricuspid valve no abscess is seen there is tricuspid regurgitation present could not be qualified impression no vegetations or intracardiac thrombus seen mild global biventricular systolic dysfunction mild to moderate mitral regurgitation cta chest impression pulmonary emboli extending from the distal right main pulmonary artery to segmental level in right upper and middle lobes and subsegmental level in right lower lobe no left sided pulmonary emboli difficult to exclude right heart strain echocardiogram would further assess no focal consolidation mild nodular contour of the liver raise concern for cirrhosis correlation with liver function test is recommended for further evaluation status post splenectomy u s of impression non occlusive deep vein thrombus of one right posterior tibial vein brief hospital course man with history of cad s p des to lad hiv on haart htn hld diabetes prostate cancer s p brachytherapy ckd salmonella splenic abscess s p splenectomy and prior hepatitis b infection admitted w submassive pe and af w rvr acute issues submassive pulmonary embolism right lower extremity dvt notable for tte with evidence of right heart strain as well as mild troponin elevation never hypotensive initiated on heparin gtt upon arrival quickly weaned to ra appears unprovoked at this time no signs of active malignancy immobilization although obese not active operations or family history transitioned to warfarin discharged on bridge atrial fibrillation w rvr no prior records of afib likely provoked pe had rates difficult to control despite escalating doses of metoprolol and initiation of po amiodarone hence he had tee and dccv successful remained in sinus at time of discharge anticoagulation as above restarted on home dose metop succinate 25mg daily after dccv continued on po amiodarone acute on chronic hfpef tte this admission w poor image quality noted depressed systolic function but could not determine ef if ef was decreased likely rate related i s o afib w rvr mildly volume overloaded on exam initially responded well to low dose iv diuresis did not require po diuretic at time of discharge rle cellulitis noted upon arrival nonpurulent started on cephalexin for oronary artery disease s p des to lad mild troponin elevation likely reflective of right heart strain from acute pe chest pain free continued asa statin and bb as above d c d plavix given initiation of ac and year since stent placement radiographic liver abnormality mild nodular contour of the liver raises concern for cirrhosis consider outpatient fibroscan and possibly hepatology referral core measures hiv most recent vl undetectable cd4 of continued home haart regimen darunavir mg po qhs cobicistat mg po qhs odefsey mg oral qhs hyperlipidemia fenofibrate mg po daily in addition to statin both home meds diabetes held po meds placed on insulin sliding scale transitional issues given unprovoked pe ensure age appropriate malignancy screening has been done if unremarkable consider hypercoagulability w u currently on lovenox bridge until warfarin therapeutic increased warfarin dose to 10mg daily on day of discharge will need close monitoring and titration of warfarin dose d c lovenox when inr of hearts monitor at time of discharge po amiodarone started i s o difficult to control af w rvr please re evaluate its need moving forward cephalexin for rle cellulitis for day course please re evaluate leg pt diabetic and high risk for pvd consider noninvasive flow studies repeat tte in several weeks to eval interval change from prior define ef ensure not newly reduced monitor for signs of increased volume start diuretic as necessary outpatient fibroscan and possibly hepatology referral given liver appearance on imaging high risk for nash on asa plavix upon arrival for des in given year and placed on warfarin d c d plavix use medications on admission the preadmission medication list is accurate and complete fenofibrate mg po daily rosuvastatin calcium mg po qpm losartan potassium mg po daily triamcinolone acetonide cream appl tp bid clopidogrel mg po daily odefsey emtricitab rilpivir tenofo ala mg oral daily darunavir mg po daily cobicistat mg po daily metoprolol succinate xl mg po daily aspirin mg po daily discharge medications amiodarone mg po tid cephalexin mg po q6h duration days enoxaparin sodium mg sc bid warfarin mg po daily16 glargine units breakfast aspirin mg po daily cobicistat mg po daily darunavir mg po daily fenofibrate mg po daily losartan potassium mg po daily metoprolol succinate xl mg po daily odefsey emtricitab rilpivir tenofo ala mg oral daily rosuvastatin calcium mg po qpm triamcinolone acetonide cream appl tp bid outpatient lab work please obtain an inr icd code contact phone fax discharge disposition home with service facility discharge diagnosis primary diagnosis pulmonary embolism right lower extremity deep vein thrombosis atrial fibrillation with rapid ventricular response acute on chronic heart failure with preserved ejection fraction secondary diagnosis coronary artery disease hiv diabetes mellitus ii 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 were you admitted you were admitted after we found blood clots in your lungs and legs you were also in an abnormal heart rhythm what did we do for you here we started you on blood thinners for the clots we then shocked your heart back into a normal rhythm what do you need to do when you leave it is really important that you take your blood thinner warfarin as prescribed you need to have regular blood checks to make sure the blood thinner is at a good level inr between and you need to see a cardiologist heart doctor after you leave the hospital you were discharged on an event monitor that will record your heart rhythm if it is triggered if you feel palpitations trigger the monitor so your cardiologist can see if your heart goes back into an abnormal rhythm please weigh yourself every morning if your weight increases by more than 3lbs in one day or lbs in one week please call your cardiologist to consider adding a medicine that will keep the extra fluid out of your body we wish you the best of health your care team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies erythromycin base biaxin ciprofloxacin attending chief complaint dyspnea major surgical or invasive procedure catheter insertion filter placement with duodenal ulcer clipping history of present illness mr is a man with a history of cad s p des to lad hiv on haart htn hld diabetes prostate cancer s p brachytherapy ckd salmonella splenic abscess s p splenectomy and prior hepatitis b infection who was admitted with a submassive pe and af with rvr on until at he is now presenting with dyspnea in the setting of being off anticoagulation since in the setting of gi and rp bleeding of note patient was recently admitted with submassive pe on mascot was consulted and he was treated and discharged on warfarin with a lovenox bridge during that admission he also had a tee dccv for new af with rvr and started on amiodarone po after discharge on patient was doing well until when he developed severe abdominal pain and was admitted to with gi and rp bleeding after admission to the floor his bp dropped to sbp for which he required norepinephrine and units prbcs patient was then discharged to rehab on off of all anticoagulation he was doing well until when he developed acute shortness of breath with mild activity getting around and new swelling in both his legs and his right arm he had no chest pain palpitations lightheadedness dizziness or syncope given these symptoms he was sent from rehab to where he was found to be hypoxemic and hypotensive to sbp a ct was performed showing a saddle pe for which he was started on heparin and transferred to past medical history pmhx pshx hiv vl cd4 500s in on antiretroviral therapy prior hepatitis b status post septic shock requiring xigris with strep viridans bacteremia acute kidney injury and cvvh in the setting of severe sepsis chronic kidney disease stage iii history of splenic abscess status post splenectomy in secondary to salmonella abscess type diabetes mellitus on insulin morbid obesity hyperlipidemia asthma right medial meniscus tear history of severe bronchitis history of mrsa colonization submassive pe dvt in retroperitoneal venous bleed in saddle pe dvt in paroxysmal atrial fibrillation with h o rvr social history family history nc physical exam admission physical examination vs t bp hr resp rate o2sa on 6l nc general well developed well nourished in nad oriented x3 mood affect appropriate heent normocephalic atraumatic sclera anicteric perrl eomi neck supple jvp not elevated cardiac rrr no m r g lungs ctab no r r w abdomen soft nt nd bs scattered bruising extremities bilateral leg edema r l skin no significant lesions or rashes pulses distal pulses palpable and symmetric discharge physical examination vs hr data last updated temp tm bp hr rr o2 sat o2 delivery 5l 2l nc 3l wt lb kg fluid balance last updated last hours total cumulative 1206ml in total 1256ml po amt 400ml iv amt infused 856ml out total 50ml urine amt 50ml last hours total cumulative 1206ml in total 1256ml po amt 400ml iv amt infused 856ml out total 50ml urine amt 50ml multiple missed voids gen morbidly obese woman lying in bed in nad heent nc at perrla eomi mmm neck supple cv rrr no murmurs pulm ctab no increased wob abd obese soft nt nd bs extr wwp no clubbing cyanosis or peripheral edema skin no significant lesions or rashes pulse distal pulses palpable and symmetric neuro aox3 grossly intact pertinent results admission labs 03pm type art po2 pco2 ph total co2 base xs 44pm hgb hct 44pm ptt 44pm 35pm type art po2 pco2 ph total co2 base xs 00pm hgb hct 00pm 17am type art po2 pco2 ph total co2 base xs 01am wbc rbc hgb hct mcv mch mchc rdw rdwsd 01am ptt 01am 26am type art po2 pco2 ph total co2 base xs 26am lactate 58am type art po2 pco2 ph total co2 base xs 58am lactate 51am glucose urea n creat sodium potassium chloride total co2 anion gap 51am alt sgpt ast sgot ld ldh alk phos tot bili 51am albumin calcium phosphate magnesium 51am wbc rbc hgb hct mcv mch mchc rdw rdwsd 51am anisocyt poikilocy macrocyt polychrom echino rbcm slide revi 51am plt smr normal plt count 51am ptt 00am hba1c eag 36am ptt 22am po2 pco2 ph total co2 base xs 22am lactate 22am o2 sat 37am voidspec specimen s 51pm glucose urea n creat sodium potassium chloride total co2 anion gap 51pm estgfr using this 51pm ctropnt probnp 51pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 51pm neuts lymphs monos eos basos nuc rbcs im absneut abslymp absmono abseos absbaso 51pm plt count 51pm ptt pertinent labs 00am blood hba1c eag 29am blood vitb folate pertinent studies cxr findings lung volumes are low bilaterally there has been interval placement of a right chest port with tip overlying the cavoatrial junction streaky linear bibasilar opacities likely represent atelectasis there is no focal consolidation effusion or pneumothorax the cardiomediastinal silhouette is likely mildly enlarged although this is likely exaggerated by low lung volumes and the ap technique no acute osseous abnormalities are identified impression interval placement of a right chest port with tip overlying the cavoatrial junction no pneumothorax redemonstration hypoinflated lungs with lower lobe volume loss pulmonary arteriogram comparison cta chest from outside facility technique dr and dr interventional and dr interventional radiology fellow performed the procedure anesthesia mac sedation was provided by anesthesia medications a total of mg of tpa were infused during the procedure contrast ml of optiray contrast fluoroscopy time and dose minutes mgy procedure right ij central venous access under ultrasound guidance left pulmonary arteriogram left pulmonary artery chemical thrombolysis lysis catheter placement in the left lower lobe pulmonary artery right pulmonary arteriogram right pulmonary artery mechanical and chemical thrombolysis repeat right pulmonary arteriogram lysis catheter placement in the right lower lobe pulmonary artery procedure details following the discussion of the risks benefits and alternatives to the procedure written informed consent was obtained from the patient the patient was then brought to the angiography suite and placed supine on the exam table a pre procedure time out was performed per protocol the neck and both groins were prepped and draped in the usual sterile fashion preliminary ultrasound images of the right ij were stored the overlying skin was anesthetized with lidocaine solution a gauge needle was advanced into the right ij under ultrasound guidance a microwire was advanced through the needle into the a small skin was made at the needle insertion site the needle was exchanged for a micropuncture access sheath the wire and inner dilator were removed wire was advanced into the the micro sheath was then exchanged for a sheath the inner dilator and wire were then removed a c2 cobra glide catheter and glidewire were then advanced through the sheath and used to navigate into the left pulmonary artery the wire was removed at this point the catheter was used to measure pulmonary artery pressures the left mean pulmonary artery pressure was contrast was injected to confirm positioning a digital was retracted left pulmonary arteriogram was performed demonstrating large filling defect in the proximal pulmonary artery and a paucity of lower lobe pulmonary artery branches at this point the patient s hemodynamic status began to decline mg of diluted tpa were injected directly into the proximal thrombus a wire was then advanced through the cobra catheter which was subsequently exchanged for a cm ekos infusion catheter a gauge needle was advanced into the right ij at a separate access site under ultrasound guidance a microwire was advanced through the needle into the a small skin was made at the needle insertion site the needle was exchanged for a micropuncture access sheath the wire and inner dilator were removed wire was advanced into the the micro sheath was then exchanged for a sheath the cobra catheter was advanced through the new sheath and navigated into the right pulmonary artery with a glidewire glidewire was removed contrast was injected to confirm positioning a digitally subtracted right pulmonary arteriogram was performed demonstrating proximal thrombus and near complete occlusion of the right lung sparing only segments in the right upper lobe mg of dilute tpa were infused directly into the thrombus a wire was advanced through the cobra catheter the cobra catheter was exchanged for a omni flush catheter the omni flush catheter was used to perform mechanical thrombectomy as an additional mg of tpa were infused the wire was injected advanced through the omni flush catheter the omni flush catheter was then removed the sheath was exchanged for an sheath a penumbra aspiration catheter was advanced over the wire and into the right pulmonary artery the aspiration catheter was used for thrombectomy transiently shortly after initiation of thrombectomy the patient s hemodynamic status significantly improved the aspiration catheter was then exchanged over a wire for the omni flush catheter a repeat digitally subtracted right pulmonary arteriogram was performed demonstrating improved flow the right lung the wire was then advanced through the omni flush catheter and positioned in the right lung base the omni flush catheter was then exchanged for a cm ekos infusion catheter contrast was injected through both ekos catheters to confirm positioning the coast catheters were then assembled unattached to respective devices both sheaths and infusion catheters were secured to the skin with silk suture a sterile dressing was applied the patient tolerated the procedure well there were no immediate post procedure complications the patient was transferred to the icu in stable condition findings pulmonary arteriograms demonstrated extensive thrombosis bilaterally local tpa was infused total of mg post thrombolysis thrombectomy arteriogram showed improvement in pulmonary arterial flow successful placement of bilateral pulmonary arterial ekos lysis catheters impression successful pulmonary arterial thrombus debulking successful placement of bilateral pulmonary arterial ekos lysis catheters tte conclusion there is mild symmetric left ventricular hypertrophy with a normal cavity size there is normal regional left ventricular systolic function overall left ventricular systolic function is normal the visually estimated left ventricular ejection fraction is moderately dilated right ventricular cavity with moderate global free wall hypokinesis there is abnormal interventricular septal motion c w right ventricular pressure overload the aortic valve leaflets are mildly thickened there is no aortic valve stenosis there is trace aortic regurgitation the tricuspid valve leaflets are mildly thickened there is mild tricuspid regurgitation there is moderate pulmonary artery systolic hypertension impression dilated right ventricle with moderate global rv systolic dysfunction moderate pulmonary hypertension ivc filter placement final report indication year old man with dvt and history of bleeding from anticoagulation ivc filter placement comparison lower extremity venous duplex dated technique dr interventional performed the procedure anesthesia lidocaine was injected in the skin and subcutaneous tissues overlying the access site medications lidocaine contrast ml of optiray contrast fluoroscopy time and dose mgy procedure ivc venogram infrarenal denali ivc filter deployment post filter placement venogram procedure details following the discussion of the risks benefits and alternatives to the procedure written informed consent was obtained from the patient the patient was then brought to the angiography suite and placed supine on the exam table a pre procedure time out was performed per protocol the right neck was prepped and draped in the usual sterile fashion an amplatz wire was placed through the existing sheath the sheath was removed over the wire and a new sheath was placed the amplatz wire was passed down into the distal ivc and left iliac vein over the wire a straight flush catheter was placed a inferior vena cava venogram was performed based on the results of the venogram detailed below a decision was made to place a denali filter the catheter and sheath were removed over the wire and the sheath of a denali filter was advanced over the wire into the ivc past the take off of the renal vessels an denali vena cava filter was advanced over the wire until the cranial tip was at the level of the inferior margin of the lower renal vein the sheath was then withdrawn until the filter was deployed the wire and loading device were then removed through the sheath and a repeat contrast injection was performed confirming appropriate filter positioning the final image was stored on pacs the sheath was removed and pressure was held for minutes at which point hemostasis was achieved a sterile dressing was applied the patient tolerated the procedure well and there were no immediate post procedure complications findings patent normal sized non duplicated ivc with single bilateral renal veins and no evidence of a clot successful deployment of an infra renal denali ivc filter cxr portable findings there is no evidence of pneumoperitoneum though detection is severely limited given patient positioning lung volumes are low bilaterally no focal consolidation is seen blunting of the left costophrenic angle is unchanged and likely secondary to pericardial fat as demonstrated on ct from the right internal jugular central line has been removed impression no evidence of pneumoperitoneum though detection severely limited by patient positioning and portable technique egd normal mucosa in the whole esophagus normal mucosa in the whole stomach oozing was noted upon entry into the duodenal bulb and duodenal sweep a single cratered 8mm ulcer was found in the duodenal sweep a visible vessel suggested recent bleeding 2ml epinephrine was successfully applied for hemostasis one endoclip was successfully applied for the purpose of hemostasis cxr for picc placement technique dr radiology attending performed the procedure anesthesia lidocaine was injected in the skin and subcutaneous tissues overlying the access site medications none contrast ml of optiray contrast fluoroscopy time and dose minutes mgy procedure replacement of right picc procedure details using sterile technique and local anesthesia the existing picc line was aspirated and flushed and a nitinol guidewire was introduced into the superior vena cava svc a peel away sheath was then placed over a guidewire the guidewire was then advanced into the superior vena cava a double lumen pic line measuring cm in length was then placed through the peel away sheath with its tip positioned in the distal svc under fluoroscopic guidance position of the catheter was confirmed by a fluoroscopic spot film of the chest the peel away sheath and guidewire were then removed the catheter was secured to the skin flushed and a sterile dressing applied the patient tolerated the procedure well there were no immediate complications findings existing right arm approach picc with tip in the axillary vein replaced with a new double lumen pic line with tip in the distal svc impression successful placement of a cm right arm approach double lumen powerpicc with tip in the distal svc the line is ready to use discharge labs 41am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 41am blood ptt 01am blood glucose urean creat na k cl hco3 angap 01am blood calcium phos mg 29am blood alt ast ld ldh alkphos totbili brief hospital course summary mr is a man with a history of cad s p des to lad hiv on haart htn hld diabetes prostate cancer s p brachytherapy ckd salmonella splenic abscess s p splenectomy and prior hepatitis b infection who was recently admitted with a submassive pe from until at he now represents with a saddle pe on ct with hypoxemia and hypotension after a recent episode of retroperitoneal hemorrhage leading to hemorrhagic shock and withholding of all anticoagulation since coronaries s p des to lad pump lvef rhythm sinus transitional issues follow ups please ensure patient keeps his f u on will set up a clinic appointment to assess for ivc filter removal in months medications patient started on warfarin for treatment of massive pe inr goal given severe rp and gi bleeds on anticoagulation bridge with enoxaparin mg bid for inr patient will need long term management of anticoagulation with warfarin pcp aware discharged on ppi bid given gi bleed on anticoagulation discontinue po ppi in weeks glargine 60u at home discharged on 50u given lower requirements during hospitalization increase back prn issues for rehab please monitor the patient s weight and attempt to uptitrate diuresis as needed to achieve his dry weight of 274lbs for cardiology po amiodarone started i s o difficult to control af w rvr please re evaluate its need moving forward repeat tte in month to eval interval change from prior define ef ensure not newly reduced for pcp given unprovoked pe ensure age appropriate malignancy screening has been done if unremarkable consider hypercoagulability w u mildly nodular contour seen on abdominal imaging consider outpatient fibroscan and possibly hepatology referral pt is high risk for nash data discharge hb no need to recheck if not having melena dry wt lbs last pre discharge 08lbs bed weight on code status full acute issues massive pulmonary embolism acute on chronic hypoxic respiratory failure patient recently admitted for submassive pe and discharged on with warfarin and a lovenox bridge presented later that month to and was found to have gi bleeding as well as a large rp bleed and the decision was made to stop his anticoagulation he was discharged to rehab and represented with dyspnea found to have a mass pe initially requiring pressor support immediately after arriving on the floor patient was taken to suite where two ekos catheters were placed for tpa administration during procedure local tpa boluses were administered to the clot and a catheter was used break up the clot the patient was started on a heparin drip ekos catheters were removed later that day transthoracic echo showed a dilated right ventricle associated with dysfunction patient also had moderate pulmonary hypertension given his edematous appearance the patient was diuresed with iv lasix and eventually transitioned to po lasix 20mg daily on patient had a ivc filter placed successfully the patient was continued on a heparin drip and converted to warfarin his inr goal was determined to be given high risk of major bleed as well as high risk of life threatening clot on discharge inr was ugib on ac s p clipping of duodenal ulcer the patient was started on warfarin overnight on the patient had multiple melanotic stools with associated hemoglobin drop from to the patient received units of packed red blood cells with good response he was taken to endoscopy by gastroenterology and had a duodenal ulcer clipped with appropriate hemostasis on discharge he was having soft brown bms he will be continued on a ppi on discharge for weeks discharge hemoglobin was atrial fibrillation w rvr had new onset afib with rvr during previous hospitalization to submassive pe had dccv successful remained in sinus at time of discharge anticoagulation as above his home metoprolol was held in the setting of acute pulmonary embolus associated with right ventricular dysfunction his amiodarone was adjusted to mg twice daily as he had already been appropriately loaded with amiodarone on his prior hospitalization on discharge we continued him home metoprolol succinate coronary artery disease s p des to lad mild troponin elevation likely reflective of right heart strain from acute pe he was chest pain free throughout the hospitalization he was continued on his home rosuvastatin and losartan his metoprolol was held during the admission in the setting of severe rv systolic dysfunction as well as the ugib it was able to restarted on discharge acute on chronic hfpef the patient had increased volume on examination with a tte showing an lv ef of he was volume overloaded on examination and required lasix iv which had good effect we converted him to po lasix regimen and would like his facility to continue to monitor the patients weight with a plan to have him lose another pounds from his admission to the facility he should have daily weights at the facility chronic issues hiv most recent vl undetectable cd4 of continue the patient on his home darunavir cobicistat and odefsey hyperlipidemia continued fenofibrate mg po daily in addition to statin both home meds diabetes held po meds and home liraglutide as it was nonformulary placed on 40u glargine qam 60u at home as well as insulin sliding scale instead in the setting of acute illness on discharge uptitrated glargine to 50u radiographic liver abnormality mild nodular contour of the liver raises concern for cirrhosis consider outpatient fibroscan and possibly hepatology referral medications on admission the preadmission medication list is accurate and complete metoprolol succinate xl mg po daily fenofibrate mg po daily rosuvastatin calcium mg po qpm glargine units breakfast liraglutide mg subcutaneous daily odefsey emtricitab rilpivir tenofo ala mg oral daily amiodarone mg po tid prezcobix darunavir cobicistat mg mg oral daily discharge medications ascorbic acid mg po daily duration days aspirin mg po daily furosemide mg po daily pantoprazole mg po q12h md to order daily dose po daily16 zinc sulfate mg po daily duration days amiodarone mg po daily glargine units breakfast insulin sc sliding scale using hum insulin fenofibrate mg po daily liraglutide mg subcutaneous daily metoprolol succinate xl mg po daily odefsey emtricitab rilpivir tenofo ala mg oral daily prezcobix darunavir cobicistat mg mg oral daily rosuvastatin calcium mg po qpm discharge disposition extended care facility discharge diagnosis primary diagnosis massive pulmonary embolism upper gi bleeding s p duodenal ulcer clipping acute on chronic hypoxic respiratory afib with rvr coronary artery disease acute on chronic heart failure with preserved ejection fraction secondary diagnosis hiv hyperlipidemia diabetes mellitus discharge condition mental status clear and coherent level of consciousness alert and interactive activity status out of bed with assistance to chair or wheelchair discharge instructions discharge instructions dear mr why were you admitted to the hospital you were admitted to the hospital because you had blood clots in your lungs what was done while you were in the hospital we gave you medications to break up the clots we started you on a blood thinning medication unfortunately you had a small gastrointestinal bleed which was fixed by our gastroenterologist what do you need to do when you leave the hospital take all of your medications as prescribed listed below especially your warfarin your goal inr is follow up with your doctors as listed below weigh yourself every morning seek medical attention if your weight goes up more than lbs medical attention if you have new or concerning symptoms or you develop swelling in your legs abdominal distention or shortness of breath at night please see below for more information on your hospitalization it was a pleasure taking part in your care here at we wish you all the best your care team followup instructions

name unit no admission date discharge date date of birth sex f service orthopaedics allergies quaternium potassium dichronate balsam of nickel paraben fragrances glycerol monothiogylconate tea tree oil benzoyl peroxide attending complaint right knee osteoarthritis major surgical or invasive procedure r tkr history of present illness year old female with right knee osteoarthritis now s p r tkr past medical history pmh hld htn oa thyroid nodule gerd depression shx 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 aquacel dressing with scant serosanguinous drainage thigh full but soft no calf tenderness strength silt nvi distally toes warm pertinent results 30am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 40am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 06am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30am blood plt 40am blood plt 06am blood plt 06am blood glucose urean creat na k cl hco3 angap 06am blood calcium phos mg 00am blood hbsag neg hbsab pos 00am blood hiv ab neg 00am blood hcv ab neg 06am blood 00am blood 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 unremarkable otherwise pain was controlled with a combination of iv and oral pain medications the patient received aspirin mg twice daily for dvt prophylaxis starting on the morning of pod the surgical dressing will remain on until pod after surgery 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 dressing was intact the patient s weight bearing status is weight bearing as tolerated on the operative extremity ms is discharged to home with services in stable condition medications on admission the preadmission medication list is accurate and complete valsartan mg po daily betamethasone augmented topical bid atorvastatin mg po qpm omeprazole mg po daily loratadine mg po daily sertraline mg po daily discharge medications acetaminophen mg po q8h aspirin mg po bid docusate sodium mg po bid gabapentin mg po tid oxycodone immediate release mg po q4h prn pain moderate senna mg po bid atorvastatin mg po qpm betamethasone augmented topical bid loratadine mg po daily omeprazole mg po daily sertraline mg po daily valsartan mg po daily 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 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 until cleared by your physician anticoagulation please continue your aspirin mg twice daily with food for four weeks to help prevent deep vein thrombosis blood clots continue pantoprazole daily while on aspirin to prevent gi upset x weeks if you were taking aspirin prior to your surgery take it at mg twice daily until the end of the weeks then you can go back to your normal dosing wound care please remove aquacel dressing on pod after surgery it is okay to shower after surgery after days but no tub baths swimming or submerging your incision until after your four week checkup please place a dry sterile dressing on the wound after aqaucel is removed 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 physical therapy 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 treatments frequency remove aquacel pod after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed staple removal and replace with steri strips at follow up visit in clinic followup instructions

name unit no admission date discharge date date of birth sex f service surgery allergies aspirin sulfasalazine lisinopril codeine nitrofurantoin sulfa sulfonamide antibiotics attending chief complaint abdominal pain major surgical or invasive procedure none history of present illness is a w hx of htn and iddm who is presenting here to the ed for a day hx of rlq abd pain she says she has never had these sx before ros is diffusely ve including n v loose stools melena lightheadedness and or dizziness ros is o w ve except as noted above her labs show wbc and a ct a p was obtained which showed a dilated appendix to cm diameter w surrounding fat stranding and phlegmon c f appendicitis for which we were consulted past medical history dm2 htn hyperlipidemia depression anxiety iron deficiency anemia gerd chronic back pain insomnia tongue cancer sees specialist at h o stomach ulcers social history family history she had brother with lung ca daughter with endometrial cancer physical exam physical examination upon admission temp hr bp resp o sat normal constitutional patient is well appearing and in no acute distress heent normocephalic atraumatic pupils equal round and reactive to light extraocular muscles intact neck is supple chest clear to auscultation cardiovascular regular rate and rhythm normal first and second heart sounds abdominal soft nondistended tender to palpation in the left lower quadrant and suprapubic region with voluntary guarding rectal heme positive extr back no cyanosis clubbing or edema skin no rash warm and dry neuro speech fluent moving all extremities psych normal mood normal mentation physical examination upon discharge vital signs t hr bp rr room air general nad cv ns1 s2 no murmurs lungs coarse bs bil abdomen soft non tender ext no pedal edema bil no calf tenderness bil neuro alert and oriented x pertinent results 18am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 20am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 50pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 50pm blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 18am blood plt 18am blood glucose urean creat na k cl hco3 angap 20am blood glucose urean creat na k cl hco3 angap 50pm blood glucose urean creat na k cl hco3 angap 50pm blood alt ast alkphos totbili 18am blood calcium phos mg 26am blood hba1c eag cat scan abd pelvis dilated appendix measuring cm with significant surrounding fat stranding compatible with acute appendicitis of note the appearance is slightly atypical given isolated involvement of the appendiceal base with the inflammation centered at the base of the cecum and appendix the mid to distal appendix and including the tip are all normal in appearance no evidence of perforation or abscess brief hospital course year old female admitted to the hospital with abdominal pain upon admission the patient was made npo given intravenous fluids and underwent a cat scan which showed a dilated appendix the patient underwent serial abdominal examinations and placed on bowel rest she was placed on a course of ciprofloxacin and flagyl during the patient s hospitalization she was noted to have elevated blood sugars the diabetes was consulted for recommendations in blood sugar management on hd the patient s abdominal pain decreased and she was started on clear liquids and advanced to a regular diet her white blood cell count normalized the patient was discharged home with her family on hd her vital signs were stable and she was afebrile she had return of bowel function and was voiding without difficulty the patient was instructed to complete a course of ciprofloxacin and flagyl discharge instructions were reviewed and questions answered a follow up appointment was made in the acute care clinic medications on admission the preadmission medication list may be inaccurate and requires futher investigation propranolol mg po bid atorvastatin mg po qpm amlodipine mg po daily mirtazapine mg po qhs omeprazole mg po daily paroxetine mg po daily discharge medications ciprofloxacin hcl mg po ng q12h duration days rx ciprofloxacin hcl cipro mg tablet s by mouth every twelve hours disp tablet refills glargine units bedtime humalog units breakfast humalog units lunch humalog units dinner insulin sc sliding scale using hum insulin metronidazole mg po q8h rx metronidazole mg tablet s by mouth every eight hours disp tablet refills amlodipine mg po daily atorvastatin mg po qpm mirtazapine mg po qhs omeprazole mg po daily paroxetine mg po daily propranolol mg po bid discharge disposition home discharge diagnosis acute appendicitis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions you were admitted to the hospital with lower abdominal pain and tarry stools you underwent cat scan imaging which showed acute appendicitis you were started on antibiotics and your white blood cell count was monitored during your hospital stay you were noted to have elevation in your blood sugars and the diabetes was consulted and made adjustments in your diabetes medication your vital signs have been stable and you are preparing for discharge with the following recommedations 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 or abdominal pain 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 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 followup instructions

name unit no admission date discharge date date of birth sex f service neurology allergies alendronate sodium attending chief complaint disinhibited conduct progressively worsening gait and large volume urinary incontinence major surgical or invasive procedure none history of present illness the patient is a yo woman with medical history of htn gerd and recent personality changes presenting to the ed sent from her assisted living facility with weeks of disinhibited conduct progressively worsening gait and large volume urinary incontinence per discussion with her son she has been in with subtle cognitive decline she had been doing well there until the end of however he reports in the last weeks she has shown significant personality changes including disinhibition aggression yelling hitting staff and becoming very confrontational which is out of her character he also complains she has developed gait instability initially requiring a walker and much worse in the last week to the point that she is unable to stand on her own and has been requiring a wheelchair to get around she also has large volume urinary incontinence during the same period which is new for her per her pcp she was initially evaluated in at the time she was having mild psychiatric issues which she describes as hallucinations and flight of ideas she was started on seroquel bid with significant improvement at the time she was described as verbose but appropriate she was seen again by dr weeks ago for evaluation of falls up to three times per day she was also acting inappropriately disrobing herself in her living facility at the time the case was discussed with a neurologist at which thought she may have frontal lobe syndrome mri mra was performed which per report showed lacunar infarcts moderate atrophy and small vessel ischemic disease at some point during the last weeks he was admitted to a psych facility and started on zoloft remeron and seroquel her son reports she takes ativan 1mg tid for many decades for anxiety on arrival to the ed she was agitated requiring lorazepam 2mg po total seroquel 25mg po x1 and home depakote mg psychiatry evaluated and confirmed recommended thiamine supplementation due to concerns for wernike s on neurologic review of systems the patient denies headache lightheadedness or confusion denies difficulty with producing or comprehending speech denies loss of vision blurred vision diplopia vertigo tinnitus hearing difficulty dysarthria or dysphagia denies focal muscle weakness numbness parasthesia denies loss of sensation reports bladder incontinence firmly denies difficulty with gait on general review of systems the patient denies chest pain palpitations dyspnea or cough denies nausea vomiting diarrhea constipation or abdominal pain past medical history htn gerd lt radial fracture with hardware in place recently seen by neurologist at w frontal lobe syndrome per psych note no psych history prior who is sent via from her assisted living facility for significantly worsening aggression impulsivity and gait disturbance over the last two months social history family history mother died of possible mi at yo dad died at age of unknown causes son healthy physical admission exam vitals ra general nad heent ncat no oropharyngeal lesions neck supple rrr no m r g pulmonary ctab no crackles or wheezes abdomen soft nt nd bs no guarding extremities warm no edema neurologic examination ms awake alert oriented x able to relate history with difficulty as rationalizes her gait issues by saying her socks are sticky her shoes were tight or her toenails were too long inattentive unable to name backwards as she writes them down fwd and then reads them in bw order speech is fluent with full sentences intact repetition and intact verbal comprehension content of speech bizarre as describes formed hallucinations when i close my eyes i see a bunny mood is labile able to follow both midline and appendicular commands cranial nerves perrl 3mm brisk eomi no nystagmus 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 no deficits to light touch but patient would not allow us to touch her feet any further to assess for proprioception dtrs bi tri pat ach l r plantar response upgoing bilaterally unable to test for jaw jerk due to poor cooperation coordination no dysmetria with finger to nose testing bilaterally gait testing attempted but patient with broad base stance and significant retropulsion unable to stand unassisted discharge exam essentially unchanged vs t bp hr rr o2 ra gen awake in bed nad heent nc at neck supple cv warm well perfused pulm normal inspiratory effort abd soft nt nd ext no clubbing cyanosis or edema ms alert oriented x3 verbally combative throughout exam unable to perform luria sequence states moyf and moyb recall with categories spontaneously repeated the words correctly minutes later naming intact repetition and comprehension intact able to read and write follows commands but perseverates on prior task cn perrl limited upgaze otherwise eomi face symmetric tongue midline intact sensation in v1 v3 motor mildly increased tone postural tremor l r bilateral delt bic tri ip b l giveway weakness bilateral quad ham bilateral ta gas dtr r toe down l toe mute palmar mental reflex r l glabellar reflex jaw jerk bi tri pat ach l r sensory intact to light touch throughout coordination intact finger to nose mild postural tremor bilaterally finger tapping more clumsy on l gait requires assistance to sit at the edge of bed retropulses when attempts to stand requires two person assist to stand upright pertinent results labs 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 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood ptt 24pm blood glucose urean creat na k cl hco3 angap 00am blood glucose urean creat na k cl hco3 angap 24pm blood alt ast alkphos totbili 00am blood calcium phos mg 00am blood vitb12 folate 00am blood tsh 24pm blood valproa 24pm blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg 22am urine color straw appear hazy sp 22am urine blood neg nitrite neg protein neg glucose neg ketone neg bilirub neg urobiln neg ph leuks neg csf 07pm cerebrospinal fluid csf wbc rbc polys monos eos totprot glucose fluid culture preliminary acid fast culture preliminary neg micro serology blood rapid plasma reagin test pending blood lyme lyme igg pending lyme igm pending urine culture negative imaging ct head no evidence of acute intracranial abnormalities specifically no evidence for normal pressure hydrocephalus age related global atrophy and chronic microangiopathy mild left sphenoid sinus disease brief hospital course ms is a yo woman with medical history of htn gerd and progressive personality changes presenting to the ed sent from her assisted living facility with weeks of worsening disinhibited conduct worsening gait and large volume urinary incontinence diagnosed with fronto temporal dementia neurologic exam is limited by labile mood but notable for numerous frontal signs including inattention disinhibition inability to perform luria sequence brisk but symmetric reflexes and significant retropulsion with attempted gait assessment nchct with evidence of atrophy especially frontally and small vessel ischemic disease history exam and imaging most consistent with fronto temporal dementia likely exacerbated by chronic vascular dementia csf studies were normal and showed no evidence of infection or inflammatory process opening pressure was slightly elevated at 21cm however this done in with the patient supine rather in flexed lateral position and likely represents false elevation suspicion was low for nph she is medically cleared for discharge studies for lyme and syphilis are pending but these are sufficiently unlikely given the overall clinical presentation that their pending status should not be a barrier to discharge to an appropriate care facility she was evaluated by psychiatry who assessed the determined her to meet for inability to care for self in the community absence of insight into her care needs or presentation and that she would benefit from an admission to a facility see note from dr dementia likely frontotemporal dementia continue divalproex tid consider increasing if lfts stable stop memantine continue quetiapine 25mg qhs prn continue lorazepam taper to discontinuation currently 5mg bid home 1mg tid contributing to disinhibition cv hypertension continue atenolol 25mg bid consider resumption of home 50mg dose or switch to agent with more cns effects such as propranolol medications on admission the preadmission medication list is accurate and complete omeprazole mg po daily sertraline mg po daily quetiapine fumarate mg po bid atenolol mg po bid divalproex delayed release mg po tid mirtazapine mg po qhs lorazepam mg po tid vitamin d unit po daily cyanocobalamin mcg po daily discharge medications acetaminophen mg po q8h prn pain mild divalproex sod sprinkles mg po tid docusate sodium mg po bid heparin unit sc bid senna mg po hs thiamine mg po daily atenolol mg po bid lorazepam mg po bid quetiapine fumarate mg po qhs prn agitation cyanocobalamin mcg po daily omeprazole mg po daily sertraline mg po daily vitamin d unit po daily discharge disposition extended care facility discharge diagnosis frontotemporal dementia discharge condition mental status confused sometimes level of consciousness alert and interactive activity status out of bed with assistance to chair or wheelchair discharge instructions ms you were admitted for symptoms of disinhibited conduct including physical aggression and worsening gait upon evaluation you did not have evidence for any infectious inflammatory or other treatable cause for these symptoms you showed neuropsychiatric signs consistent with a form of dementia that initially affects executive function inhibition and planning you will be referred to a care facility that specializes in this and similar conditions and they will be best able to care for you we made the following changes to your medications weaning your ativan lorazepam this worsens cognitive function and disinhibition stop remeron mirtazapine as it did not be appear to be having any effect and in order to simplify your medication regimen reduce seroquel quetiapine from 25mg twice per day to 25mg at night if needed this medicine is for agitation which was not prominent during your stay and can be used for now only when needed in order to avoid excessive sedation thank you your neurology 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 decubitus pressure ulcer major surgical or invasive procedure none history of present illness with a pmh of t10 paraplegia gsw with chronic decubitus ulcers and history mrsa abscesses recently seen for perirectal abscess with i d and l ischial decubitus ulcer presenting for worsening of his decubitus ulcer he states the ulcer has worsened over the past several weeks and the air mattress cushion device he had been using for the ulcer broke several weeks ago he was seen in earlier today for this complaint and was referred to the ed for evaluation of possible infection related to his ulcer he also describes some hot cold sensations although he has not checked his temperature to note a frank fever he notes this may be similar to prior symptoms that he has with utis he performs cic and denies any recent changes in his urine or difficulty with catheterization he denies any cough or shortness of breath he has been eating and drinking well without significant abdominal pain he endorses increased constipation he endorses increased pain at first stating everywhere and then saying specifically over his decub ulcer in the ed initial vitals were ra labs were significant for wbc plt lactate ct revealed inflammation surrounding decubitus ulcer without evidence of deep tissue infection or osteomyelitis surgery was consulted who did not feel that the patient required surgical management of his decub and who recommended admission to medicine for workup of leukocytosis past medical history paraplegia after gun shout wound from t10 level downward chronic back pain partial right lung resection for gsw recurrent mrsa skin abcesses in neck back perianal recently admitted in recurrent sacral decubitus ulcers status post debridement in the or on and growing mrsa pseudomonal prostatic abscess in prostatis in recurrent uti past cultures have grown enterococcus morganella pseudomonas cocaine use with history of perforated nasal septum urinary incontinence chronically self catheterizes grade internal hemorrhoids seen on sigmoidoscopy chronic constipation depression adhd g6pd mutation diagnoses depression add no hx o psychosis prior to what is described in hpi prior hospitalizations 1x this month as per hpi history of assaultive behaviors denies history of suicide attempts or self injurious behavior denies prior med trials report being on wellbutrin concerta longstanding has tried ritalin social history born in raised in completed high school in and some post grad training has one son now yo who he still sees currently living in assisted living facility substance abuse history etoh denies tobacco denies mj lsd ecstasy mushrooms report last mj use cocaine crack amphetamines has significant history of cocaine dependence now in remission c b perforated septum reports last use opiates denies ivdu on opioids for pain question of misuse of prescriptions benzos denies family history notable for bpad sister cousin maternal gm physical exam admission physical exam vitals tc bp hr rr o2 sat ra general lying in bed on anterior side slightly somnolent with some mumbled responses to questions nad heent sclera anicteric mmm eomi perrl neck supple jvp normal heart rrr s1 s2 no r g m lungs ctab abdomen soft non tender non distended bowel sounds in all four quadrants gu no foley extremity wwwp no c c e left ischial sacral decub with significant protuberance without surrounding erythema or undermining no rectal abscess neuro ox3 motor exam c w t10 paralysis skin tattoo of gun over left chest tribal tattoo on left forearm scar on right shoulder s p gsw scars in lower spine s p gsw discharge physical exam vitals tm tc hr rr on ra general lying in bed on r side awake and alert pleasant nad heent sclera anicteric mmm eomi perrl neck supple jvp normal heart rrr s1 s2 no r g m lungs ctab abdomen soft non tender non distended bowel sounds in all four quadrants gu no foley extremity wwwp no c c e left ischial sacral decub with no longer significant protuberance no surrounding erythema or undermining no rectal abscess neuro aox3 motor exam c w t10 paralysis skin r buttock decubitus ulcer approx 6cm in diameter with granulated base clean margins no purulence tattoo of gun over left chest tribal tattoo on left forearm scar on right shoulder s p gsw scars in lower spine s p gsw pertinent results admission labs 12pm ptt 07pm urine hours random 07pm urine uhold hold 07pm urine color yellow appear hazy sp 07pm urine blood neg nitrite neg protein glucose neg ketone tr bilirubin neg urobilngn ph leuk lg 07pm urine rbc wbc bacteria few yeast none epi 07pm urine amorph rare 07pm urine mucous rare 00pm lactate k 00pm lactate k 35pm voidspec qns 25pm glucose urea n creat sodium potassium chloride total co2 anion gap 25pm estgfr using this 25pm crp 25pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 25pm neuts lymphs monos eos basos im absneut abslymp absmono abseos absbaso 25pm plt count imaging ct pelvis left decubitus ulcer without associated drainable fluid collection or subcutaneous emphysema underlying bone is unremarkable 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 40am blood calcium phos mg ssessment plan with a pmh of t10 paraplegia presenting with worsened decub ulcer found to have uti with enterococcus sensitive to ampicillin uti wbc on admission elevated lactate and ua with significant wbcs consistent with uti patient had no pulmonary signs ctab satting weel on room air and decubitus ulcer discussed in section below on exam and ct imaging showed no signs of infection given the patient s need for self straight catheterization he is at risk for recurrent utis he was started on ctx 1g q24 while urine cultures pending during this time he had one episode of nausea vomiting and had diaphoresis overnight urine cultures grew enterococcus sp sensitive to ampicllin patient was started on amoxicillin clavulanic acid mg po ng q12h for day course note amoxicillin clavulanic acid po was used vs amoxicillin po due to availability of proper dose medications in hospital at time of discharge leukocytosis and symptoms of tachycardia nausea vomiting and diaphoresis had resolved patient was advised on sterile technique for straight catheterization left decubitus pressure ulcer on admission mr was found to have an unstageable decubitus pressure ulcer on the left buttock it had been increasing in size for the past weeks he was initially started on vancomycin in the ed however this was discontinued on the floor there was no evidence of infection of the ulcer on imaging or physical examination surgery evaluated ulcer and decided no surgical intervention was indicated wound care team was consulted and was able to remove slough via cross hatching from the ulcer to reveal a stage pressure ulcer throughout mr stay there was no evidence of infection of the ulcer wound care recommendations were following including keeping the wound clean and keeping pressure off the left buttock it was noted the ulcer progression was due to a broken pressure mattress and no longer working roho cushion for his wheel chair before discharge replacements for both were arranged along with evaluation for home wound care assistance constipation on arrival to the floor the patient reported he had not had bm in several days he was started on polyethylene glycol docusate and senna with good effect he began to have regular non bloody stool without issue depression mr has a history of depression and was initially noted to have a sad affect in the morning during rounds he was evaluated by who recommended considering alternative or additional medications to treat depression which has limited his activity at home during this stay he was maintained on home dose of risperidone and bupropion nicotine use given mr history of tobacco use he was given a nicotine patch mg td daily while inpatient chronic pain mr pain regimen was continued during his inpatient stay with oxycodone immediate release mg po ng q4h prn pain morphine sr ms mg po q8h and gabapentin mg po ng tid transitional issues uti enterococcus on regimen amoxicillin clavulanic acid mg po ng q12h x days total last day wheel chair and mattress cushion ordered need to be delivered will help ensures this occurs decubitus ulcer wound care recommendations clean with commercial wound cleanser or normal saline pat tissue dry with dry gauze apply thin layer of normlgel cover with mepilex border change every days and prn when out of bed limit sit time to one hour at a time and sit on a pressure redistribution cushion roho elevate while sitting patient evaluated for depression which appears poorly controlled currently please consider further evaluation for alternative or additional medicine beside wellbutrin 300mg po daily medications on admission the preadmission medication list is accurate and complete bupropion sustained release mg po bid gabapentin mg po tid morphine sr ms mg po q8h oxybutynin mg po bid oxycodone immediate release mg po q6h prn pain risperidone mg po bid tamsulosin mg po qhs ascorbic acid mg po bid methenamine hippurate gram oral bid discharge medications ascorbic acid mg po bid bupropion sustained release mg po bid gabapentin mg po tid morphine sr ms mg po q8h oxybutynin mg po bid oxycodone immediate release mg po q6h prn pain risperidone mg po bid tamsulosin mg po qhs methenamine hippurate gram oral bid amoxicillin clavulanic acid mg po q12h rx amoxicillin pot clavulanate augmentin mg mg tablet s by mouth twice a day disp tablet refills discharge disposition home with service facility discharge diagnosis primary decubitus pressure ulcer uti secondary constipation depression chronic pain discharge condition mental status clear and coherent level of consciousness alert and interactive activity status out of bed with assistance to chair or wheelchair discharge instructions dear mr you were admitted to because of a worsening ulcer on your left buttock and symptoms suggestive of a urinary tract infection uti a ct scan of your pelvis did not show evidence of infection though the ulcer did appear worse from previous descriptions you were seen by wound care who provided dressing recommendations to help heal physical therapy and case management also procured the appropriate cushion and mattress to prevent further pressure ulcer formation they will be shipped to your house on admission you were also found to have a urinary tract infection you were started on iv antibiotics and once cultures came back you were transitioned to and antibiotic called augmentin with a plan to take for a total of days last day roho cushion and a the proper mattress to reduce pressure ulcers are planned to be delivered to your home these have been ordered but can take weeks to arrive it was a pleasure taking care of you during your stay at we wish you the best in your ongoing recovery if you have any questions about the care you received please do not hesitate to ask sincerely your care team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies aspirin attending chief complaint syncope major surgical or invasive procedure none history of present illness year old gentleman with history of paraplegia from gun shot wound neurogenic bladder recurrent utis chronic pain hx of cocaine abuse hx of psychosis transferred from for evaluation of syncope yesterday am patient was found by side of road by police after he fell out of his wheelchair by police patient reports he syncopized unclear how long he was out for he was brought by ems to per notes he had negative ct head and ct c spine he was evaluated by psychiatric team who recommended discharge home however mother endorsed concern of multiple episodes of syncope he was transferred to for syncope evaluation patient provides a rambling and unclear history he says he was outside yesterday to get coffee going uphill in his wheelchair and then lost consciousness and fell backwards out of his chair he also provides an incoherent history of being dragged in the mud by people he was with and he perseverates on the fact that this dirtied his clothes and his white which he normally keeps very clean his speech is quite pressured and tangential during this part of the history he denies cocaine use and cannot explain why his tox screen is positive he is not able to provide meaningful details of his history of syncope he tells me he syncopized 5x in past week his only associated symptom is feeling warm denies chest respiratory symptoms or seizure like activity in the ed he endorsed syncopizing up to 5x daily there was concern for psychosis mentioned by pcp in recent note patient endorsed visual hallucinations and paranoia of government following him there is a question of history of bipolar disorder not currently treated he does not follow with a psychiatrist in the ed initial vitals were ra labs notable for wbc chem7 wnl ua with lg leuks 44wbc few bac ketones urine cocaine pos urine opiates pos lactate he was given iv ceftriaxone gm decision was made to admit for syncope evaluation and inpatient psych consult on arrival to the floor he is calm but appears altered he has at times difficult to comprehend rambling and pressured speech he denies hi si or hallucinations currently ros also notable for cloudy urine recently otherwise as per hpi full point ros negative except as noted in hpi past medical history paraplegia after gun shout wound from t10 level downward chronic back pain partial right lung resection for gsw recurrent mrsa skin abcesses in neck back perianal recently admitted in recurrent sacral decubitus ulcers status post debridement in the or on and growing mrsa pseudomonal prostatic abscess in prostatis in recurrent uti past cultures have grown enterococcus morganella pseudomonas cocaine use with history of perforated nasal septum urinary incontinence chronically self catheterizes grade internal hemorrhoids seen on sigmoidoscopy chronic constipation depression adhd g6pd mutation diagnoses depression add no hx o psychosis prior to what is described in hpi prior hospitalizations 1x this month as per hpi history of assaultive behaviors denies history of suicide attempts or self injurious behavior denies prior med trials report being on wellbutrin concerta longstanding has tried ritalin social history born in raised in completed high school in and some post grad computer training has one son now yo who he still sees currently living in assisted living facility recently fired his pca on who was taking care of assistance with his adls food and meds now in the process of hiring his son as his new pca substance abuse history etoh denies tobacco denies mj lsd ecstasy mushrooms report last mj use cocaine crack amphetamines has significant history of cocaine dependence now in remission c b perforated septum reports last use but was found with cocaine in his urine on this admission in opiates denies ivdu on opioids for pain question of misuse of prescriptions benzos denies family history notable for bpad and schizophrenia sister cousin maternal gm physical exam admission exam vital signs ra general awake but extremely somnolent falling asleep numerous times during interview arousable to voice heent sclera anicteric mmm oropharynx clear eomi perrl neck supple cv regular rate and rhythm normal s1 s2 no murmurs rubs gallops lungs diffusely diminished bilaterally no crackles abdomen soft diffuse mild discomfort to deep palpation gu no foley no external lesions skin 1x1cm superficial ulceration r gluteus covered in clean dressing appears non erythematous and non purulent ext warm non edematous neuro full upper extremity muscle strength strength bilaterally psych denies hallucinations hi si pressured speech at times tangentiality and circumstantiality discharge exam vs tc bp hr rr o2 ra general awake alert nad pleasant heent sclera anicteric mmm eomi perrl heart rrr normal s1 s2 no m r g lungs ctab no crackles abdomen soft non tender non distended gu no foley no external lesions rectal prostate tender to palpation skin 1x1cm superficial ulceration r gluteus covered in clean dressing appears non erythematous and non purulent ext warm non edematous neuro aox3 cnii xii grossly intact pertinent results admission labs chem 00pm glucose urea n creat sodium potassium chloride total co2 anion gap 00pm calcium phosphate magnesium cbc 00pm wbc rbc hgb hct mcv mch mchc rdw rdwsd urine 29pm urine rbc wbc bacteria few yeast none epi 29pm urine blood neg nitrite neg protein tr glucose tr ketone bilirubin neg urobilngn ph leuk lg 30pm urine bnzodzpn neg barbitrt neg opiates pos cocaine pos amphetmn neg oxycodn neg mthdone neg pertinent labs 35am blood tsh 45am blood free t4 micro pm urine final report urine culture final acinetobacter baumannii complex cfu ml note for amp sulbactam higher than standard dosing needs to be used since therapeutic efficacy relies on intrinsic activity of the sulbactam component piperacillin tazobactam sensitivity testing available on request enterococcus sp cfu ml sensitivities mic expressed in mcg ml acinetobacter baumannii complex enterococcus sp ampicillin s ampicillin sulbactam s cefepime s ceftazidime i ciprofloxacin i gentamicin s levofloxacin s meropenem s nitrofurantoin s tetracycline r tobramycin s trimethoprim sulfa s vancomycin s studies eeg this is an abnormal continuous icu eeg monitoring study because of a slow and poorly modulated background consistent with a mild to moderate encephalopathy findings were provided to the clinical team intermittently during this recording period ct c spine w o contrast no acute abnormality suspected findings consistent with multilevel cervical spondylosis ct head w o contrast no acute intracranial abnormality cxr pa lateral no acute cardiopulmonary process discharge labs none except ua after as patient was stable chem 45am blood glucose urean creat na k cl hco3 angap cbc 45am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ua 45pm urine blood neg nitrite neg protein neg glucose neg ketone neg bilirub neg urobiln neg ph leuks neg brief hospital course is a year old male with a history of t10 paraplegia neurogenic bladder recurrent utis recent pre admission question of paranoia psychosis who presented with syncope multiple times daily patient reported losing consciousness up to 5x day daily for months all work up was unremarkable eeg showed mild encephalopathy but no seizures ct head and c spine showed mild cervical spondylosis orthostatics negative telemetry without events patient reported that he had no episodes of syncope in the hospital and none were witnessed psychiatry evaluated the patient and diagnosed schizophrenia with psychosis exacerbated by drug and medication use cocaine and concerta and started the patient on risperdal syncope was felt to be psychiatric in nature however history also notable for significant caffeine intake in addition to adhd medication and severe insomnia active problems syncope unclear etiology never witnessed by the patient s family and has not had any events during this hospitalization no history of seizures question of whether this was a case of psychiatric syncope which typically presents in younger patients with psychiatric disorders without cardiovascular or neurologic disease another consideration was drug med effect from opiates other illegal drugs given that the patient s urine tox was positive for opiates on ms and cocaine the patient emphasized how little he sleeps stays up late playing video games watching tv often only gets hours of sleep a night and somnolence secondary to this was felt to be a contributing factor as well given that the patient had no episodes in the hospital and was well rested here also endorsed drinking multiple caffeinated drinks daily in addition to adhd medication not felt to be cardiac or neurogenic as ecg telemetry and eeg showed nothing except for mild encephalopathy ultimately felt when discharged that this would continue to resolve with improved psychiatric care as outlined below psychosis with suspected schizophrenia based upon rambling and disorganized speech in addition to delusions of the government following him confirmed by his family he also previously endorsed paranoia and visual hallucinations per psych likely chronic and then triggered by cocaine and possibly other drug use and concerta uti felt to have contributed to the patient s decompensation as well thyroid function appeared normal tsh was low but barely below low normal limits and free t4 was well within normal limits so hyperthyroidism was felt much less likely additionally he had no other physiologic symptoms of hyperthyroidism the patient s morphine was tapered since he violated his narcotics contract and his home concerta was held indefinitely his uti was treated as noted below and he was started on risperidone qhs per psych he recently fired his pca on who was helping with adls food meds because he thought she was not helping much and just taking his money he and his son on discharge were setting up his son as his new pca he was also set up with a partial day psych program in order to expedite his outpatient psych care given difficulty getting him a psychiatry appointment because of the patient s insurance cystitis prostatitis as below patient reported cloudy urine self caths due to neurogenic bladder spinal cord injury from gun shot wound ua was grossly positive urine culture grew acinetobacter baumannii sensitive to bactrim and enterococcus sp sensitive to ampicillin his antibiotic course was as follows ampicillin po mg q6h bactrim ds bid empiric ceftriaxone acute bacterial prostatitis tender on digital rectal exam performed on day of discharge with concern given recurrent utis and reported bladder discomfort discharged on bactrim x weeks for prostatitis given senses on initial culture counseled on clean self cath routine l hallux trauma patient stubbed toe with skin tear recommend ongoing dressing changes daily and monitoring for improvement chronic stable problems depression continued wellbutrin adhd discontinued concerta and did not resume on discharge as noted above chronic pain continued gabapentin morphine taper mg twice daily from then mg daily from the patient had diarrhea when this was initially held patient violated his narcotics contract prior to admission with illicit drug use chronic issues r gluteal wound daily dressing changes neurogenic bladder continued home tamsulosin mirabegron methenamine transitional issues anti psychotic medication management risperdal started in the hospital and psych follow up partial day psych program intake scheduled for at am gluteal wound care and left toe wound care with home bactrim x weeks for prostatitis taper down ms mg twice daily from then mg daily from because patient violated narcotics contract son will be patient s new personal care assistant medications on admission the preadmission medication list may be inaccurate and requires futher investigation bupropion sustained release mg po bid collagenase ointment appl tp daily r thigh fluticasone propionate nasal spry nu daily gabapentin mg po tid methenamine hippurate gram oral bid concerta methylphenidate mg oral daily mirabegron mg oral daily morphine sr ms mg po tid prn pain tamsulosin mg po qhs acetaminophen mg po q8h prn pain mild ascorbic acid mg po bid docusate sodium mg po bid ibuprofen mg po q6h prn pain mild polyethylene glycol g po daily prn constipation discharge medications risperidone mg po qhs rx risperidone risperdal mg tablet s by mouth daily disp tablet refills sulfameth trimethoprim ds tab po bid rx sulfamethoxazole trimethoprim bactrim ds mg mg tablet s by mouth twice a day disp tablet refills morphine sr ms mg po q12h acetaminophen mg po q8h prn pain mild ascorbic acid mg po bid bupropion sustained release mg po bid collagenase ointment appl tp daily r thigh docusate sodium mg po bid fluticasone propionate nasal spry nu daily gabapentin mg po tid ibuprofen mg po q6h prn pain mild methenamine hippurate gram oral bid mirabegron mg oral daily oxybutynin mg po daily polyethylene glycol g po daily prn constipation tamsulosin mg po qhs discharge disposition home with service facility discharge diagnosis primary diagnosis psychosis nos cocaine abuse secondary diagnosis adhd depression chronic pain from right gluteal decubitus ulcer discharge condition mental status confused sometimes level of consciousness alert and interactive activity status out of bed with assistance to chair or wheelchair discharge instructions dear mr why you were here you were hospitalized because you were having episodes of confusion loss of consciousness and were found to have a urinary tract infection what we did and found urine tests which showed two types of bacteria and cocaine eeg brain wave test which did not show seizures ct scan of your head and neck which showed no problems what should you do now taper down ms as directed in your discharge instructions get at least hours of sleep each night and do not drink any energy drinks or coffee after noontime stop taking concerta continue risperidone mg nightly it is very important that you follow up with the partial psych program that was arranged for you you can also call psychiatry at once you are home to set up an outpatient appointment please continue to take the antibiotics for your infection for weeks until they are finished it was a pleasure meeting and taking care of you while you were in the hospital your team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies aspirin attending chief complaint acute pyelonephritis major surgical or invasive procedure none history of present illness with paraplegia as a result of a gsw neurogenic bladder with chronic intermittent straight caths with recurrent utis with various organisms now on chronic suppressive methenamine who presented on with c o foul smelling and cloudy urine rectal pain and burning and low bilateral back pain he notably has a h o prostate abscess in as well as chronic sacral decubitus ulcer for which he has been treated multiple times with antibiotics including an osteomyelitis course in for mrsa currently the wound is closed urine cultures in the past have grown a large range of organisms resistant at times he reports that the current symptoms have been ongoing for between weeks he went to the er at an outside hospital about a week ago and reportedly he had a ua that showed infection and he was given an unknown medication which he reports was an antibiotic that contained aspirin he only took one dose the symptoms progressed he feels that this is beyond a usual uti he has had a low appetite no n v no diarrhea he endorses feeling hot subjective fevers but does not have a thermometer also endorses intermittent sweats he denies penile discharge nor genital lesions he has not been sexually active for several months of note he also states that he has a face abscess he noticed right facial swelling and pain around the lip and nose about a week and a half ago and went to a dentist who felt he likely had an infection at the root of tooth pt states xray was done he was therefore started on amoxicillin about weeks ago and told that he needs a root canal on that tooth the area is improved and he finished the amoxicillin the urinary symptoms developed while on amoxicillin here vs notable for mild tachycardia he underwent ct of the abdomen pelvis which noted cystitis and his chronic sacral decubitus no comment on the prostate ua showed wbc neg leuk esterase neg nitrite ros gen fevers chills weight loss eyes photophobia visual changes heent oral gum bleeding cardiac chest pain palpitations edema gi nausea vomiting diarrhea abdominal pain constipation hematochezia pulm dyspnea cough hemoptysis heme bleeding lymphadenopathy gu dysuria hematuria incontinence skin rash endo heat cold intolerance msk myalgia arthralgia back pain neuro numbness weakness vertigo headache past medical history paraplegia after gun shout wound from t10 level downward chronic back pain partial right lung resection for gsw recurrent mrsa skin abcesses in neck back perianal recently admitted in recurrent sacral decubitus ulcers status post debridement in the or on and growing mrsa pseudomonal prostatic abscess in prostatis in recurrent uti past cultures have grown enterococcus morganella pseudomonas cocaine use with history of perforated nasal septum urinary incontinence chronically self catheterizes grade internal hemorrhoids seen on sigmoidoscopy chronic constipation depression adhd g6pd mutation diagnoses depression add no hx o psychosis prior to what is described in hpi prior hospitalizations 1x this month as per hpi history of assaultive behaviors denies history of suicide attempts or self injurious behavior denies prior med trials report being on wellbutrin concerta longstanding has tried ritalin social history born in raised in completed high school in and some post grad computer training has one son now yo who he still sees currently living in assisted living facility recently fired his pca on who was taking care of assistance with his adls food and meds now in the process of hiring his son as his new pca substance abuse history etoh denies tobacco denies mj lsd ecstasy mushrooms report last mj use cocaine crack amphetamines has significant history of cocaine dependence now in remission c b perforated septum reports last use but was found with cocaine in his urine on this admission in opiates denies ivdu on opioids for pain question of misuse of prescriptions benzos denies family history notable for bpad and schizophrenia sister cousin maternal gm physical exam admission physical exam vss ra gen in moderate distress holding abdomen pain heent eomi mmm op lesions pul cta b l cor rrr s1 s2 mrg abd moderate diffuse ttp nd bs cvat ext cce neuro caox3 parapalegic discharge pe ra gen nad sitting comfortably in bed eomi perrla mmm cv rrr nl s1s2 no m r g resp ctab no w r r abd soft mild lower abdominal tenderness no guarding or rebound nd bs back no cva tenderness ext no c c e neuro cn ii xii intact strength upper extremities paraplegic psych pleasant but bizarre comments skin warm dry chronic well healed scars on sacrum buttocks without erythema or drainage pertinent results 54pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 54pm blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 54pm blood hypochr normal anisocy normal poiklo normal macrocy normal microcy normal polychr normal 54pm blood glucose urean creat na k cl hco3 angap 54pm blood alt ast alkphos totbili 54pm blood lipase 54pm blood albumin calcium phos mg 54pm blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg 07pm blood lactate 10pm urine color straw appear clear sp 10pm urine blood neg nitrite neg protein neg glucose neg ketone neg bilirub neg urobiln neg ph leuks sm 10pm urine rbc wbc bacteri few yeast none epi pm urine final report urine culture final escherichia coli cfu ml cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h doxycycline fosfomycin and minocycline sensitivities testing per resistant to doxycycline resistant to minocycline sensitive to fosfomycin doxycycline minocycline and fosfomycin sensitivity testing performed by sensitivities mic expressed in mcg ml escherichia coli ampicillin r ampicillin sulbactam r cefazolin s cefepime s ceftazidime s ceftriaxone s ciprofloxacin r gentamicin s meropenem s nitrofurantoin s piperacillin tazo s tobramycin s trimethoprim sulfa r chest portable ap study date of impression no acute intrathoracic process retained bullet fragments in the mid back ct abd pelvis with contrast study date of impression chronic decubitus ulcer overlying the left ischial spine without associated drainable fluid collection or subcutaneous air diffuse mild urinary bladder wall thickening consistent with chronic cystitis discharge labs 40am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 40am blood glucose urean creat na k cl hco3 angap year old male with pmh of paraplegia neurogenic bladder requiring intermittent straight caths recurrent uti psychotic disorder and chronic pain presenting with fever foul smelling urine abdominal back and rectal pain sepsis without organ dysfunction due to e coli acute bacterial prostatitis and uti febrile at home here with low grade fevers tachycardia and severe leukocytosis urinalysis showing some pyuria but not very impressive he is complaining of significant rectal pain and prostate exam significant for tender mildly enlarged prostate he has recently completed a week course of bactrim for possible prostatitis cultures growing e coli resistant to bactrim and fluoroquinolones initially was put on vancomycin ceftaz id was consulted once sensitivities returned discharged on fosfomycin for a week course his leukocytosis quickly resolved abdominal and rectal pain improved he was initially given opioids for the pain which was quickly weaned off f u with id as scheduled continue po fosfomycin for total week course day d c suppressive methenamine tylenol ibuprofen for pain neurogenic bladder requiring straight catheterization spastic bladder continue intermittent straight cath continue oxybutinin tamsulosin mirabegron chronic pain continue suboxone gabapentin tylenol and ibuprofen depression possible psychotic disorder continue bupropion risperdal chronic constipation continue polyethylene glycol colace senna fen ppx regular heparin sc full code dispo home with services medications on admission the preadmission medication list may be inaccurate and requires futher investigation acetaminophen mg po q8h prn pain mild bupropion sustained release mg po bid collagenase ointment appl tp daily r thigh docusate sodium mg po bid fluticasone propionate nasal spry nu daily gabapentin mg po tid tamsulosin mg po qhs polyethylene glycol g po daily prn constipation ascorbic acid mg po bid ibuprofen mg po q6h prn pain mild methenamine hippurate gram oral bid mirabegron mg oral daily risperidone mg po qhs oxybutynin mg po daily morphine sr ms mg po q12h sulfameth trimethoprim ds tab po bid discharge medications fosfomycin tromethamine g po asdir duration weeks every other day for three doses then every third day rx fosfomycin tromethamine monurol gram packet s by mouth as directed disp packet refills ibuprofen mg po q6h prn pain mild acetaminophen mg po q8h prn pain mild ascorbic acid mg po bid buprenorphine naloxone 8mg 2mg tab sl daily bupropion sustained release mg po bid collagenase ointment appl tp daily r thigh docusate sodium mg po bid fluticasone propionate nasal spry nu daily gabapentin mg po tid mirabegron mg oral daily oxybutynin mg po bid polyethylene glycol g po daily prn constipation risperidone mg po qhs tamsulosin mg po qhs discharge disposition home with service facility discharge diagnosis sepsis due to e coli uti and acute bacterial prostatitis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status out of bed with assistance to chair or wheelchair discharge instructions dear mr you were admitted with fevers foul smelling urine abdominal and rectal pain you were found to have a urinary tract infection and a prostate infection we are sending you on a long course of antibiotics to try to cure the infection in your prostate please follow up with your primary care physician and infectious disease as scheduled followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies aspirin attending chief complaint cc wound eval major surgical or invasive procedure none history of present illness mr is a yo man with h o t10 paraplegia and recurrent utis who presents via own wheelchair to the ed with multiple concerns including bed sores new uti and fever as well as wanting detox from heroin on review of the record the patient was last seen in clinic by dr on at which time he was sober and being followed by he was subsequently seen in the bid ed on for recurrent uti discharged with cipro despite cultures showing resistance to this he appears to have most recently contacted his pcp with recurrent uti sx was prescribed 9d of fosfomycin of note discharged on wks of fosfomycin for e coli prostatitis with resistance to ampicillin augmentin ciprofloxacin tmp smx but susceptible to cephalosporins had single follow up visit with id in early his most recent positive urine culture was from once again showed e coli with similar resistance pattern and additional resistance to gentamicin in terms of his opioid use disorder patient reports he has been to multiple detox facilities as well has had outpatient services he was previously on suboxone last months ago at which time he relapsed he has intermittently relapsed and has been discharged from multiple facilities due to inability to keep appointments he feels depressed with when he relapses which is what prompted him to come to the ed during this time he is motivated to stay sober this time around in the ed initial vs were ra exam notable for paraplegia abdomen soft stage sacral ulcers bilateral ekg not visible on dash labs showed cbc mcv n bmp k bun cr gluc ua sg leuk lg prot glu ket tr wbc bact few epi tox serum negative asa etoh acetmnphn benzo barb tricyc urine positive cocaine urine negative benzos barbs opiates amphet mthdne oxycodone imaging showed cxr findings the lungs are hyperexpanded expanded but clear there is no pleural abnormality the heart size is within normal limits the mediastinal and hilar contours unremarkable calcific density projecting over the lower thoracic vertebra are unchanged in configuration consults psychiatry no s12 will contact best to look for eats dual diagnosis unlocked unit if patient attempting to leave prior to placement please call psych for re eval for opioid withdrawal would recommend clonidine 1mg bid hold for sbp hr or orthostatic changes robaxin 750mg q6h prn muscle pain cramps bentyl 20mg po q4h prn gi cramps vistaril 50mg im po q4h prn anxiety kaopectate ml po prn after each loose stool acetaminophen 650mg q6h prn pain page with questions patient received ceftriaxone 1gm iv x2 ns 1l x1 transfer vs were ra on arrival to the floor patient reports feeling well endorses story above he reports he was supposed to have an appointment with his pcp today but went to the ed due to symptoms of dysuria and urinary frequency for the past days despite taking fosfomycin as well as wanting to be placed in a facility to detox he was also concerned that he possibly may have pyelonephritis as he has had this previously and persistent pain in his l buttock where he has a pressure ulcer past medical history paraplegia after gun shout wound from t10 level downward chronic back pain partial right lung resection for gsw recurrent mrsa skin abcesses in neck back perianal recently admitted in recurrent sacral decubitus ulcers status post debridement in the or on and growing mrsa pseudomonal prostatic abscess in prostatis in recurrent uti past cultures have grown enterococcus morganella pseudomonas cocaine use with history of perforated nasal septum urinary incontinence chronically self catheterizes grade internal hemorrhoids seen on sigmoidoscopy chronic constipation depression adhd g6pd mutation diagnoses depression add no hx o psychosis prior to what is described in hpi prior hospitalizations 1x this month as per hpi history of assaultive behaviors denies history of suicide attempts or self injurious behavior denies prior med trials report being on wellbutrin concerta longstanding has tried ritalin social history born in raised in completed high school in and some post grad training has one son now yo who he still sees currently living in assisted living facility recently fired his pca on who was taking care of assistance with his adls food and meds now in the process of hiring his son as his new pca substance abuse history etoh denies tobacco denies mj lsd ecstasy mushrooms report last mj use cocaine crack amphetamines has significant history of cocaine dependence now in remission c b perforated septum reports last use but was found with cocaine in his urine on this admission in opiates denies ivdu on opioids for pain question of misuse of prescriptions benzos denies family history notable for bpad and schizophrenia sister cousin maternal gm physical exam admission physical exam admission physical exam vs po r sitting ra general nad heent eomi perrl anicteric sclera mmm poor dentition neck supple no lad no jvd heart rrr s1 s2 no murmurs gallops or rubs lungs ctab abdomen nt mildly firm bs no hepatosplenomegaly extremities muscle wasting neuro a ox3 strength in ue bilaterally intact rectal tone gu no prostate tenderness on dre skin warm and well perfused stage pressure ulcer on the l buttock discharge physical exam vs temp po bp l hr rr o2 sat o2 delivery ra general nad heent eomi perrl anicteric sclera mmm poor dentition neck supple no lad no jvd heart rrr s1 s2 no murmurs gallops or rubs lungs ctab abdomen nt mildly firm bs no hepatosplenomegaly extremities muscle wasting neuro a ox3 strength in ue bilaterally intact rectal tone skin warm and well perfused pertinent results admission labs 59am wbc rbc hgb hct mcv mch mchc rdw rdwsd 59am neuts monos eos basos im absneut abslymp absmono abseos absbaso 59am plt count 35am urine hours random 35am urine bnzodzpn neg barbitrt neg opiates neg cocaine pos amphetmn neg oxycodn neg mthdone neg 35am urine color yellow appear hazy sp 35am urine blood neg nitrite neg protein glucose ketone tr bilirubin neg urobilngn ph leuk lg 35am urine rbc wbc bacteria few yeast none epi 35am urine mucous few 40am glucose urea n creat sodium potassium chloride total co2 anion gap 40am estgfr using this 40am asa neg ethanol neg acetmnphn neg bnzodzpn neg barbitrt neg tricyclic neg imaging cxr impression no focal consolidation no evidence of pneumonia ct a p impression x cm oval shaped hypodensity in the right posterolateral prostatic apex is similar in appearance to prior mri from and may represent a chronic abscess or phlegmon consider pelvic mri for further evaluation no ct evidence of pyelonephritis or renal abscess diffuse fecal loading throughout the large bowel mri impression no prostatic abscess or phlegmon specifically abnormality noted on ct from within right peripheral zone corresponds to normal prostatic parenchyma evidence of prior prostatitis within left peripheral zone chronic bilateral sacral decubitus ulcers of note study is not dedicated for evaluation of osteomyelitis and the findings are markedly improved compared to prior mr final report urine culture final enterobacter cloacae complex cfu ml this organism may develop resistance to third generation cephalosporins during prolonged therapy therefore isolates that are initially susceptible may become resistant within three to four days after initiation of therapy for serious infections repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used staphylococcus saprophyticus presumptive identification cfu ml routine susceptibility testing of urine isolates of s saprophyticus is not advised because infections respond to concentrations achieved in urine of antimicrobial agents commonly used to treat acute uncomplicated urinary infections e g nitrofurantoin trimethoprim trimethoprim sulfamethoxazole or a fluoroquinolone sensitivities mic expressed in mcg ml enterobacter cloacae complex cefepime s ceftazidime s ceftriaxone s ciprofloxacin s gentamicin s meropenem s nitrofurantoin i piperacillin tazo s tobramycin s trimethoprim sulfa s discharge labs 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 brief hospital course mr is a year old man with paraplegia as a result of a gsw neurogenic bladder with chronic intermittent straight caths with recurrent utis with various organisms now on chronic suppressive methenamine presenting with urinary tract infection passive and opioid withdrawal symptoms acute issues opioid withdrawal detox history of polysubstance abuse passive serum and urine tox screens on admission only positive for cocaine as per prior records enrolled in multiple detox programs previously but discharged due to inconsistent medication use and lost to follow up evaluated by psych given passive on presentation but not sectionable on their evaluation recommended best screening for placement vs ccs dual diagnosis unit unable to successfully place this patient in above during the hospitalization hiv hcv checked for risk stratification and returned negative initiated on suboxone while inpatient as patient was having mild withdrawal symptoms not controlled with other medications with improvement plan to follow up with dr from psychiatry for suboxone uti w history of drug resistant e coli history of prostatitis symtpoms and ua consistent with uti started on iv ceftriaxone on prophylactic methenamine hippurate on admission though from prior id notes likely not providing much benefit as urine ph on testing has been too high to activate the drug urine culture growing cephalosporin fluoroquinoline sensitive enterobacter ct a p obtained to r o chronic abscess vs phlegmon though no signs of this on pelvic mri transitioned from iv ceftriaxone to po ciprofloxacin on discharge plan for week course for early seeding of the prostate end date on discharge for uti ppx id recommended 3g fosfomycin po q10 days rather than methanamine chronic issues neurogenic bladder continued xxybutynin mg po bid takes er mg daily at home tamsulosin mg po qhs with intermittent straight caths chronic constipation continue bowel regimen prn history of bipolar vs schizophrenia not currently taking any medications chronic low back pain continued gabapentin mg po tid acetaminophen mg po q8h prn pain mild transtional issues last date of ciprofloxacin start fosfomycin 3g po q10 days on id pcp and psychiatry for suboxone follow up as above medications on admission the preadmission medication list may be inaccurate and requires futher investigation gabapentin mg po tid tamsulosin mg po qhs ascorbic acid mg po bid methenamine hippurate gram oral bid oxybutynin chloride mg oral daily discharge medications buprenorphine naloxone 8mg 2mg tab sl daily ciprofloxacin hcl mg po q12h rx ciprofloxacin hcl mg tablet s by mouth every twelve hours disp tablet refills docusate sodium mg po bid prn constipation rx docusate sodium mg tablet s by mouth bid prn disp tablet refills fosfomycin tromethamine g po q10days uti prophylaxis dissolve in oz ml water and take immediately rx fosfomycin tromethamine monurol gram packet s by mouth q10days disp packet refills polyethylene glycol g po tid prn constipation rx polyethylene glycol miralax gram powder s by mouth tid prn disp packet refills senna mg po bid prn constipation rx sennosides senna mg tablets by mouth bid prn disp tablet refills gabapentin mg po tid rx gabapentin mg tablet s by mouth three times a day disp tablet refills oxybutynin chloride mg oral daily rx oxybutynin chloride mg tablet s by mouth daily disp tablet refills tamsulosin mg po qhs rx tamsulosin mg capsule s by mouth at bedtime disp capsule refills discharge disposition home discharge diagnosis complicated urinary tract infection opioid dependence with withdrawal discharge condition mental status clear and coherent level of consciousness alert and interactive activity status out of bed with assistance to chair or wheelchair discharge instructions dear mr you were admitted to for a urinary tract infection we started you on intravenous antibiotics we did imaging to make sure that you did not have an abscess of your prostate we transitioned you to an oral antibiotic that you will take until you also started experiencing withdrawal symptoms while here we started you on suboxone and arranged for you to follow up with dr for this it was a pleasure caring for you wishing you the best your team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies aspirin attending chief complaint pyelonephritis major surgical or invasive procedure none history of present illness mr is a with pmh of history of unspecified psychotic disorder bipolar vs schizophrenia and significant cocaine and opioid use disorders sober mo prostatic abscess and t10 paraplegia gsw in with neurogenic bladder resulting in recurrent utis who presents today with flank pain and foul smelling urine the symptoms started a week ago but have worsened over the past days prompting him to present to the ed over the past week the patient noticed a foul odor in his urine with purulent discharge and bilateral flank pain these symptoms felt similar to his prior kidney infections he describes subjective fevers and chills neck pain and joint pains in the small joints of his hands he has had chronic mild abdominal tenderness that initially improved after having a bowel movement yesterday but worsened somewhat today he is taking all his medications as prescribed but forgot to take fosfomycin over the past weeks and feels this may have triggered a uti of note pt was seen in clinic in he had been performing straight catheterization every few hours and has noted improvement over the past several months with weekly fosfomycin therapy as the frequencies of infections has decreased however earlier that month he had sign symptoms of a uti for which he was prescribed ciprofloxacin and treated with days ros he denies any uri symptoms n v dysuria chest pain dyspnea palpitations headache or paresthesias he states that he feels like is developing an ulcer in his left buttock area as well has had bilateral blurry vision since starting zoloft weeks ago which prompted him to discontinue the medication ed course exam nad b l flank pain normal mentation wheelchair bound labs notable for wbc ua pos for nitrites and leuks with wbc and bacteria pt received il ns and 1g ctx at pm past medical history paraplegia after gun shout wound from t10 level downward chronic back pain partial right lung resection for gsw recurrent mrsa skin abcesses in neck back perianal recently admitted in recurrent sacral decubitus ulcers status post debridement in the or on and growing mrsa pseudomonal prostatic abscess in prostatis in recurrent uti past cultures have grown enterococcus morganella pseudomonas cocaine use with history of perforated nasal septum urinary incontinence chronically self catheterizes grade internal hemorrhoids seen on sigmoidoscopy chronic constipation depression adhd g6pd mutation diagnoses depression add no hx o psychosis prior to what is described in hpi prior hospitalizations 1x this month as per hpi history of assaultive behaviors denies history of suicide attempts or self injurious behavior denies prior med trials report being on wellbutrin concerta longstanding has tried ritalin social history born in raised in completed high school in and some post grad training has one son now yo who he still sees currently living in assisted living facility recently fired his pca on who was taking care of assistance with his adls food and meds now in the process of hiring his son as his new pca substance abuse history etoh denies tobacco denies mj lsd ecstasy mushrooms report last mj use cocaine crack amphetamines has significant history of cocaine dependence now in remission c b perforated septum reports last use but was found with cocaine in his urine on this admission in opiates denies ivdu on opioids for pain question of misuse of prescriptions benzos denies family history notable for bpad and schizophrenia sister cousin maternal gm physical exam general pleasant gentleman in hospital bed in no apparent distress eyes perrl eomi anicteric sclerae ent ears and nose without visible erythema masses or trauma posterior oropharynx without erythema or exudate uvula midline cv regular rate and rhythm normal s1 s2 no s3 no s4 no murmur no jvd pulm breathing comfortably on room air a few bibasilar crackles on chest exam good air movement bilaterally gi bowel sounds present abdomen non distended soft non tender to palpation no hsm appreciated gu no flank tenderness to palpation no suprapubic fullness or tenderness to palpation ext no lower extremity edema distal extremity pulses palpable throughout skin bilateral well healing ulcers over ischial spines intact skin and covered neuro alert oriented face symmetric gaze conjugate with eomi speech fluent bilateral lower extremities without movement baseline and sensation psych pleasant appropriate affect pertinent results recent labs micro studies 42am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 42am blood glucose urean creat na k cl hco3 angap 42am blood calcium phos mg ua hazy nit prot lg leuk rbc wbc many bacteria epithelial cells pm urine culture urine culture final escherichia coli cfu ml ertapenem and fosfomycin susceptibility testing requested per ertapenem sensitive fosfomycin sensitive escherichia coli ampicillin r ampicillin sulbactam r cefazolin r cefepime r ceftazidime r ceftriaxone r ciprofloxacin r gentamicin s meropenem s nitrofurantoin i piperacillin tazo s tobramycin r trimethoprim sulfa r brief hospital course mr is a employee of with t10 paraplegia s p gunshot wound neurogenic bladder chronic self caths living in a sober house who is admitted for pyelonephritis his urine culture growing multidrug resistant e coli most likely got pyelonephritis in setting of non adherence with home suppressive fosfomycin final sensitivities showed sensitivity to pipercillin tazobactam meropenem gentamycin ertapenem fosfomycin his sober house can t manage iv antibiotics so had to be discharged to a facility to complete his antibiotics course after initially started on ceftriaxone when sensitivities he was switched to pip tazo per id s suggestion on discharge he was switched to ertapenem to complete a day course last day he was instructed to restart his home fosfomycin when he completes his iv antibiotics while in the hospital his discomfort was treated with phenazopyridine for dysuria and his suboxone was increased from daily to bid he was discharged back on his home daily dosing he was continued on his home dose of gabapentin for neuropathic pain during the hospitalization his non formulary vyvanse for adhd was held and restarted at discharge his home venlafaxine was continued pmp was checked and was appropriate he had constipation while in the hospital treated with miralax senna docusate and prn lactulose he was continued on his home oxybutynin and tamsulosin for neurogenic bladder and continued his normal routine of serial self catheterization he had constipation while in the hospital treated with miralax senna docusate and prn lactulose he was continued on his home oxybutynin and tamsulosin for neurogenic bladder and continued his normal routine of serial self catheterization he also complained of neck pain and hand tingling and weakness so mr of the c s was done and showed djd at mult levels with cord contact and remodeling of cord without cord signal abnormality neurosurgery was consulted and recommended that he follow up as an outpatient no need for surgery or intervention at this time medications on admission the preadmission medication list is accurate and complete gabapentin mg po tid acetaminophen mg po q6h prn pain mild fever buprenorphine naloxone tablet 8mg 2mg tab sl daily ibuprofen mg po q8h prn pain mild oxybutynin xl nf mg other daily tamsulosin mg po bid prn urinary retention alprostadil mcg injection daily prn multivitamins tab po daily vyvanse lisdexamfetamine mg oral daily naloxone nasal spray mg ih asdir venlafaxine xr mg po daily polyethylene glycol g po daily discharge medications ertapenem sodium g iv 1x duration dose give on and last day fosfomycin tromethamine g po g every days dissolve in oz ml water and take immediately heparin flush units ml ml iv daily and prn line flush sodium chloride flush ml iv daily and prn line flush acetaminophen mg po q6h prn pain mild fever alprostadil mcg injection daily prn buprenorphine naloxone tablet 8mg 2mg tab sl daily gabapentin mg po tid multivitamins tab po daily naloxone nasal spray mg ih asdir oxybutynin xl nf mg other daily polyethylene glycol g po daily tamsulosin mg po bid prn urinary retention venlafaxine xr mg po daily vyvanse lisdexamfetamine mg oral daily discharge disposition extended care facility discharge diagnosis pyelonephritis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status wheelchair bedbound patient is paraplegic discharge instructions you were admitted for a kidney infection pyelonephritis probably related to not taking your fosfomycin we treated you with fluids and antibiotics your infection is resistant to many antibiotics requiring treatment with iv antibiotics instead of oral ones you are being discharged to complete your iv antibiotics at a facility afterward please restart your fosfomycin to help prevent future infections like this followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies aspirin lima beans attending chief complaint buttock pain major surgical or invasive procedure none history of present illness mr is a year old with pmh of paraplegia below t10 since age due to a gunshot wound recurrent utis self caths due to neurogenic bladder hx of prostatic abscess unspecified psychotic disorder bipolar vs schizophrenia hx of opioid use disorder on suboxone who presents with abdominal pain and cough and found to have perirectal phlegmon and being admitted for iv antibiotics patient states he was in his usual state of health until about days ago when he began having abdominal pain distention productive cough and fever to tmax just over he did not have a bowel movement for days then had a small bowel movement yesterday that was non bloody he denies n v sore throat nasal congestion dysuria in the ed initial vitals were t hr bp rr exam notable for soft tissue swelling around gluteal cleft labs notable for hgb ua with small leuk neg nitrites wbc no bacteria normal lfts and bmp imaging was notable for ct a p extensive soft tissue inflammatory changes surround the gluteal cleft and anal verge with mm radiodense focus which could represent a foreign body no drainable fluid collection no definite perianal fistula identified although close proximity to the external sphincter at o clock with linear high density tract raises this possibility pelvic mri could further evaluate phlegmon reaches superiorly near the coccyx although there are no osseous changes to raise suspicion for osteomyelitis no bowel obstruction moderate to large stool burden throughout the colon cholelithiasis cxr findings slight increased opacification overlying the upper lungs is likely due to technical factors and overlying soft tissue as the lateral radiograph demonstrates clear lungs cardiomediastinal silhouette and hila are normal no pneumothorax or pleural effusion radiopaque foreign body overlying the posterior lower thoracic spine is unchanged from multiple prior radiographs impression no evidence of pneumonia patient was seen by colorectal surgery who could not identify abscess on exam reviewed imaging with radiology and felt findings were consistent with phlegmon with no identifiable fluid collection patient was given po acetaminophen mg iv ceftriaxone gm iv metronidazole mg upon arrival to the floor patient states he is having stinging abdominal pain all over he states this has been going on for about days and has been getting progressively worse he has had worsening abdominal distention and has not had a regular bm in over days he also reports some coughing with yellow sputum production but no sore throat nasal congestion or sob he has also had pain in his perirectal area but has not been as bad as abdominal pain denies any changes in urine color or cloudy urine chills n v blood in stool or any other discharge in perianal area ros positive per hpi remaining point ros reviewed and negative past medical history paraplegia after gun shout wound from t10 level downward chronic back pain partial right lung resection for gsw recurrent mrsa skin abscesses in neck back perianal recurrent sacral decubitus ulcers status post debridement in the or on and growing mrsa pseudomonal prostatic abscess in prostatis in recurrent uti past cultures have grown enterococcus morganella pseudomonas cocaine use with history of perforated nasal septum urinary incontinence chronically self catheterizes grade internal hemorrhoids seen on sigmoidoscopy chronic constipation depression adhd g6pd mutation social history family history notable for bpad and schizophrenia sister cousin maternal gm physical exam admission physical exam vital signs temp po bp hr rr o2 sat general pleasant well appearing in no acute distress heent oropharynx clear no erythema or tonsillar swelling neck no lad cardiac regular rhythm normal rate normal s1 s2 no murmurs lungs clear to auscultation bialterally abdomen mildly distended but soft some mild discomfort with deep palpation in lower quadrants no rebound or guarding back mild left sided paraspinal muscle tenderness to palpation rectal has large bilateral sacral scars from prior infected sacral ulcers that are well healed mild tenderness to palpation just superior to anus in gluteal cleft no erythema induration or fluctuance noted no expressible discharge extremities warm with dp radial pulses neurologic paraplegia with strength in lower extremities bilaterally normalt strength in upper extremities normal sensation throughout discharge physical exam vital signs hr data last updated temp tm bp hr rr o2 sat o2 delivery ra general pleasant well appearing in no acute distress cardiac regular rhythm normal rate normal s1 s2 no murmurs lungs clear to auscultation bilaterally abdomen normal bowel sounds soft distended mildly tender to deep palpation llq no rebound or guarding extremities warm with dp radial pulses neurologic paraplegia with strength in lower extremities bilaterally normal strength in upper extremities pertinent results admission labs 16am other body fluid fluapcr negative flubpcr negative 45pm glucose urea n creat sodium potassium chloride total co2 anion gap 45pm alt sgpt ast sgot alk phos tot bili 45pm lipase 45pm albumin calcium phosphate magnesium iron 45pm caltibc ferritin trf 45pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 45pm neuts monos eos basos im absneut abslymp absmono abseos absbaso 45pm plt count 45pm ret aut abs ret 45pm urine hours random 45pm urine uhold hold 45pm urine color straw appear clear sp 45pm urine blood neg nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk sm 45pm urine rbc wbc bacteria none yeast none epi discharge labs 45am 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 imaging pelvis w w o contras impression no drainable fluid collection perianal fistula or significant phlegmonous change chronic changes in the pelvis include areas of scarring and fibrosis postsurgical changes related to sacral decubitus ulcer debridement and flap reconstruction and chronic atrophy of the levator plate mild edema and enhancement of the intersphincteric space consistent with granulation tissue suggesting chronic inflammation abd pelvis with co impression extensive soft tissue inflammatory changes surround the gluteal cleft and anal verge with mm radiodense focus which could represent a foreign body or dystrophic calcification no drainable fluid collection no definite perianal fistula identified although close proximity to the external sphincter at o clock with linear high density tract raises this possibility pelvic mri could further evaluate phlegmon reaches superiorly near the coccyx although there are no osseous changes to raise suspicion for osteomyelitis this also could be better assessed on mri no bowel obstruction moderate to large stool burden throughout the colon cholelithiasis pa lat impression no evidence of pneumonia microbiology pm urine final report urine culture final viridans streptococci cfu ml brief hospital course this is a year old with past medical history of t10 paraplegia complicated by neurogenic bladder and recurrent utis and prior prostatic abscess unspecified psychotic disorder opioid use disorder on suboxone admitted with several days of abdominal pain initial cross sectional imaging raising concern for perirectal phlegmon but subsquent mri only showing chronic changes without signs of acute infection course only otherwise notable for constipation able to be discharged home on augmented bowel regimen abnormal ct rectum patient presented with abdominal pain with ct imaging raising concern for perirectal fistula given history of mrsa he was covered empirically with iv vanc ctx and po flagyl exam only showed chronic changes subsequent mri pelvis did not show evidence of abscess fistula or phlegmon abnormalities seen on ct were thought to be chronic changes due to a healed pressure ulcer with flap as such patient was discharged home without antibiotics formal read still pending at discharge but second attending radiologist looked at the image and confirmed unofficial read of no acute infection constipation abdominal pain patient presented complaint in the ed was abdominal pain and constipation ct scan with signs of constipation without obstructin constipation thought to be secondary to suboxone pt provided with an aggressive bowel regimen eventually requiring bowel preparation to resolve constipation patient subsequently transitioned to bowel regimen with senna and miralax abdominal pain markedly improved and patient was able to be discharged home t10 paraplegia c b neurogenic bladder hx of recurrent utis w prior esbl infection hx of prostatic abscess patient has a history of recuurent utis likely related to self catheterization due to neurogenic bladder no urinary symptoms during this admission allowed patient to continue straight cath this admission continued suppression regimen of fosfomycin history of opioid use disorder in remission on suboxone and followed in clinic reports months of sobriety continued suboxone naloxone 8mg 2mg qd notified with addiction team when patient was discharged code full presumed contact hcp relationship mother phone transitional issues discharged home patient reported noncompliance with tamsulosin 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 minutes spent on discharge medications on admission the preadmission medication list is accurate and complete acetaminophen mg po q6h prn pain mild fever buprenorphine naloxone tablet 8mg 2mg tab sl daily gabapentin mg po tid multivitamins tab po daily oxybutynin xl nf mg other daily polyethylene glycol g po daily venlafaxine xr mg po daily alprostadil mcg injection daily prn naloxone nasal spray mg ih asdir vyvanse lisdexamfetamine mg oral daily fosfomycin tromethamine g po 1x week th discharge medications senna mg po bid rx sennosides senna mg tablet s by mouth twice a day disp tablet refills acetaminophen mg po q6h prn pain mild fever alprostadil mcg injection daily prn buprenorphine naloxone tablet 8mg 2mg tab sl daily fosfomycin tromethamine g po 1x week th gabapentin mg po tid multivitamins tab po daily naloxone nasal spray mg ih asdir rx naloxone narcan mg actuation spray intranasally as needed disp bottle refills oxybutynin xl nf mg other daily polyethylene glycol g po daily rx polyethylene glycol gram packet s by mouth once a day disp packet refills venlafaxine xr mg po daily vyvanse lisdexamfetamine mg oral daily discharge disposition home discharge diagnosis generalized abdominal pain secondary to constipation abnormal ct rectum t10 paraplegia c b neurogenic bladder hx of recurrent utis w prior esbl infection history of opioid use disorder in remission discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent with wheelchair discharge instructions dear mr it was a privilege caring for you at please see below for more information on your hospitalization why were you admitted to the hospital you were having pain in your buttock what was done while you were in the hospital we did imaging which was reassuring we started antibiotics for an infection on your buttock you completed your antibiotics while you were in the hospital you were constipated we gave you medications to help you have bowel movements what do you need to do when you leave the hospital take all of your medications as prescribed listed below follow up with your doctors as listed below continue your medications for constipation it is important that you have a bowel movement every day seek medical attention if you have new or concerning symptoms or you develop swelling in your legs abdominal distention rectal pain fever chills or blood in your stool it was a pleasure taking part in your care here at 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 aspirin lima beans attending chief complaint ams agitation requiring sedation intubation major surgical or invasive procedure intubation extubation history of present illness male with pmh of t10 paraplegia secondary to gunshot wound in psychiatric history bipolar disorder adhd neurogenic bladder c b recurrent utis and polysubstance use disorder who recently relapsed on cocaine and heroin who presented to the ed with confusion and altered mental status per report from his aunt patient was found to be living on the streets today and was slumped over in wheelchair and brought into the ed in the ed his initial vitals were temp tmax hr bp rr spo2 on ra on arrival he was somnolent and responsive only to sternal rub with pinpoint pupils and given mg iv narcan after which he became agitated and was yelling and combative he required restraints and then was intubated and mechanically ventilated given agitation and started on propofol and fentanyl for sedation and analgesia utox positive for cocaine opiates and methadone serum tox neg and ua consistent with uti wbc mod leuk few bacteria and given dose of ctx for ams got ct head which did not show an acute process cxr confirmed et and enteric tube placement and showed left base opacity c w atelectasis vs aspiration on arrival to the ficu he was intubated and sedated his bp was with hr in nsr ros unable to assess as patient intubated and sedated past medical history paraplegia after gun shout wound from t10 level downward chronic back pain partial right lung resection for gsw recurrent mrsa skin abscesses in neck back perianal recurrent sacral decubitus ulcers status post debridement in the or on and growing mrsa pseudomonal prostatic abscess in prostatis in recurrent uti past cultures have grown enterococcus morganella pseudomonas cocaine use with history of perforated nasal septum urinary incontinence chronically self catheterizes grade internal hemorrhoids seen on sigmoidoscopy chronic constipation depression adhd g6pd mutation social history family history notable for bpad and schizophrenia sister cousin maternal gm physical exam admission phsycial exam vs bp hr rr spo2 general intubated and sedated heent perrl sclera anicteric and without injection cardiac regular rhythm normal rate audible s1 and s2 no murmurs rubs gallops lungs clear to auscultation bilaterally with rhonchi bilaterally no wheezes abdomen normal bowels sounds soft mildly distended extremities no edema skin warm well perfused no rash stage ii sacral ulcers neurologic intubated and sedated agitated when weaned sedation discharge physcial exam hr data last updated temp tm bp hr rr o2 sat o2 delivery ra general nad pleasant heent sclera anicteric and without injection cardiac rrr no m r g lungs ctab abdomen soft nt nd extremities no edema skin warm well perfused no rash neurologic paraplegic moving upper extremities spontaneously pertinent results admission labs 56pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 56pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 56pm blood ptt 56pm blood glucose urean creat na k cl hco3 angap 56pm blood alt ast alkphos totbili 56pm blood albumin calcium phos mg 14am blood hbsag neg hbsab neg hbcab neg 56pm blood asa neg ethanol neg acetmnp neg tricycl neg 14am blood hcv ab neg 04pm blood po2 pco2 ph caltco2 base xs 04pm blood lactate imaging results imaging chest portable ap impression endotracheal tube terminates cm above the carina enteric tube courses below the diaphragm out of the field of view mild streaky left base opacity may be due to atelectasis or aspiration pneumonia would not be excluded in the appropriate clinical setting imaging ct head w o contrast impression no acute intracranial abnormality imaging chest portable ap impression comparison to the feeding tube has been pulled back the tip now projects over the gastroesophageal junction the repositioned the in the stomach it needs to be advanced by approximately cm the right picc line and the endotracheal tube are in stable position lung volumes are low and there is a new partial left lower lobe atelectasis no pneumonia no pulmonary edema imaging ct head w o contrast impression no acute intracranial abnormalities are identified no change from the previous study discharge labs 28am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 28am blood plt 28am blood glucose urean creat na k cl hco3 angap 28am blood calcium phos mg brief hospital course patient summary male with a past medical history of t10 paraplegia secondary to a gsw in and neurogenic bladder complicated by recurrent utis psychiatric history bipolar disorder add and polysubstance use disorder recently relapsed who presented to the ed with utox cocaine opiates and ams that reversed with narcan unfortunately he became acutely agitated and then required sedation and intubation he was extubated on and transferred to the medical service he improved significantly the care team was actively looking for a bed at a rehabilitation facility unfortunately he left the hospital against medical advice and eloped on with a picc line in place transitional issues needs hep b immunization consider colonoscopy as outpatient for anemia acute issues polysubstance use disorder per mother first became addicted to percocet for chronic pain from gsw since he has been living in different treatment facilities houses and has had several relapses he was most recently at and was kicked out weeks ago and became homeless he uses cocaine and opiates and urine toxicology was found to be positive in ed he is following with dr in addiction medicine addiction medicine was consulted while inpatient and made recommendations for methadone while in the hospital he received methadone daily clonidine bid we planned for him to follow up with addiction medicine as an outpatient but unfortunately he eloped from the hospital with picc line in place toxic metabolic encephalopathy resolved overdose patient was somnolent on presentation to the er and urine toxicology was positive for cocaine opiates and methadone he became agitated after receiving narcan and required sedation and intubation extubated and aaox3 at discharge neurogenic bladder history of recurrent multi drug resistant utis in setting of paraplegia and neurogenic bladder requiring intermittent straight cath treated most recently for enterobacter cloacae uti resistant to bactrim and nitrofurantoin originally treated for uti however urine culture negative so d c ctx this admission he was discharged on oxybutynin bid normocytic anemia has known normocytic anemia and recent iron studies within normal limits ferritin tibc trf baseline hb approximately on presentation to ed repeat fe studies showing ferritin tibc trf consider colonoscopy as outpatient chronic issues bipolar disorder adhd continue dextroamphetamine depression psychiatry note from np continued vyvanse and increased venlafaxine dose to mg daily unclear if pt was taking these medications in the hospital he was continued on venlafaxine with plan to follow with psychiatry as an outpatient neuropathy continued on gabapentin 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 may be inaccurate and requires further investigation ditropan xl nf mg other daily gabapentin mg po tid vyvanse lisdexamfetamine mg oral daily oxybutynin chloride mg oral daily discharge medications clonidine mg po bid dextroamphetamine mg po daily famotidine mg po q12h methadone mg po daily consider prescribing naloxone at discharge nicotine patch mg day td daily venlafaxine mg po bid gabapentin mg po tid oxybutynin chloride mg oral daily vyvanse lisdexamfetamine mg oral daily discharge disposition home discharge diagnosis primary diagnoses polysubstance use disorder toxic metabolic encephalopathy resolved overdose neurogenic bladder normocytic anemia secondary diagnoses bipolar disorder adult attention deficit hyperactivity disorder depression neuropathy discharge condition mental status clear and coherent level of consciousness alert and interactive activity status out of bed with assistance to chair or wheelchair discharge instructions dear mr it was a pleasure taking care of you at the why was i in the hospital you were found to be very confused and not responsive what happened in the hospital you were intubated and given medication to treat your addictions you became stable from a medical standpoint and the care team was actively looking for a bed at a rehabilitation facility for you unfortunately you left the hospital against medical advice and without informing your care team what should i do when i go home please continue to take all of your medications as directed please follow up with all the appointments scheduled with your doctor you for allowing us to be involved in your care we wish you all the best your healthcare team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies aspirin lima beans attending major surgical or invasive procedure none attach pertinent results admission labs 25am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 25am blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 25am blood plt 25am blood glucose urean creat na k cl hco3 angap 25am blood alt ast alkphos totbili 30am blood ck cpk 25am blood albumin calcium phos mg relevant imaging nchct impression no acute intracranial process discharge labs 47am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 47am blood plt 47am blood glucose urean creat na k cl hco3 angap 47am blood calcium phos mg brief hospital course transitional issues continue to monitor tolerance of suboxone discharged on 8mg 2mg bid close follow up with clinic social work resources for wheelchair and homeless shelter patient should have outpatient id follow up for recurrent utis needs hep b immunization consider colonoscopy as outpatient for anemia assessment and plan man with a history of t10 paraplegia neurogenic bladder with recurrent mdr utis polysubstance use disorder recent cocaine heroin relapse presenting with myalgias and change in urine odor he had eloped one day prior to admission while awaiting rehab placement he was treated for withdrawal symptoms and initiated on suboxone acute issues encephalopathy substance use disorder undomiciled withdrawal during most recent hospitalization he presented with acute cocaine opioid intoxication after stabilization he eloped from the hospital and used heroin and cocaine immediately following discharge he was found to be more somnolent prior to this admission he complained of myalgias and chills consistent with withdrawal flu pcr negative hiv negative ck and renal function intact was negative for intracranial process symptoms were thought to be secondary to substance use and improved per addiction psych the team discontinued methadone and initiated suboxone on he was also treated with clonidine and hydroxyzine for vasomotor symptoms pyuria neurogenic bladder hx of mdr uti patient has had no change in urinary symptoms and denies dysuria he has only noticed a bad smell to his urine he usually straight caths he has been afebrile without elevated wbc urine grew e coli on sensitive only to gentamicin meropenem and ertapenem prior urine culture in grew enterobacter cloacae resistant to bactrim otherwise pan sensitive ucx grew ecoli only sensitive to meropenem gentamicin id recommended repeat ua to look for persistent pyuria which showed a decrease in the number of white blood cells they recommended outpatient follow up in clinic for recurrent utis he was also continued on his home oxybutynin chronic issues bipolar disorder adhd patient continued home dextroamphetamine and venlafaxine neuropathy patient continued home gabapentin medications on admission the preadmission medication list is accurate and complete gabapentin mg po tid clonidine mg po bid venlafaxine mg po bid methadone mg po daily nicotine patch mg day td daily famotidine mg po q12h dextroamphetamine mg po daily oxybutynin chloride mg oral daily vyvanse lisdexamfetamine mg oral daily discharge medications buprenorphine naloxone tablet 8mg 2mg tab sl bid consider prescribing naloxone at discharge clonidine mg po bid dextroamphetamine mg po daily famotidine mg po q12h gabapentin mg po tid nicotine patch mg day td daily oxybutynin chloride mg oral daily venlafaxine mg po bid vyvanse lisdexamfetamine mg oral daily discharge disposition home discharge diagnosis primary substance use disorder secondary bipolar disorder neuropathy discharge condition mental status clear and coherent level of consciousness alert and interactive activity status out of bed with assistance to chair or wheelchair discharge instructions dear mr it was a pleasure taking care of you at the why was i in the hospital you returned to the hospital after leaving against medical advice due to bodyaches and chills you returned after using both cocaine and heroin what happened in the hospital you were treated for opioid withdrawal and started on suboxone daily what should i do when i go home please continue to take all of your medications as directed please follow up with all the appointments scheduled with your doctor you for allowing us to be involved in your care we wish you all the best your healthcare team followup instructions

name unit no admission date discharge date date of birth sex m service orthopaedics allergies valium attending chief complaint right ankle pain major surgical or invasive procedure right tibial intramedullary nail history of present illness hx of developmental mental delay seizure disorder and blindness resides at a group home and while at day care had a witnessed fall no head strike per staff refused to bear weight to right lower extremity significant swelling and tenderness to right lower extremity outside hospital images showed right ankle fracture transferred to for higher level care past medical history blindness mental delay seizure disorder social history family history unknown physical exam exam on discharge vs consistently tachycardic oavss general unlabored breathing on ra rle leg in aircast boot wrapped in ace bandage dressing changed today incisions clean dry intact staples in place exam limited by patient cooperation wiggles toes attempts to dorsi plantarflex ankle sensation intact over dorsum and plantar aspects of forefoot as testable foot warm and well perfused no acute distress unlabored breathing abdomen soft non tender non distended incision clean dry intact with no erythema or discharge minimal ecchymosis splint in place clean dry and intact aircast boot in place right lower extremity leg in aircast boot ace dressing clean dry intact intact toe flexion extension no pain with toe range of motion sensation intact over dorsum and plantar aspects of forefoot as testable foot warm and well perfused pertinent results 00pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 50pm blood glucose urean creat na k cl angap brief hospital course the patient presented to the emergency department and was evaluated by the orthopedic surgery team the patient was found to have right tibial and right fibular fractures and was admitted to the orthopedic surgery service the patient was taken to the operating room on for a right tibial 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 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 his rehab was appropriate the hospital course was otherwise unremarkable at the time of discharge the patient s pain was well controlled with oral medications incisions were clean dry intact and the patient was voiding moving bowels spontaneously the patient is partial weight bearing in an aircast boot in the right lower extremity and will be discharged on lovenox for dvt prophylaxis the patient will follow up with dr routine a thorough discussion was had with the patient and his caretakers 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 and his caretakers were also given written instructions concerning precautionary instructions and the appropriate follow up care the patient and his caretakers expressed readiness for discharge medications on admission the preadmission medication list is accurate and complete citalopram mg po qhs quetiapine fumarate mg po qam quetiapine fumarate mg po qhs trazodone mg po qhs trazodone mg po qam divalproex delayed release mg po bid discharge medications acetaminophen mg po q8h docusate sodium mg po daily enoxaparin sodium mg sc daily start today first dose next routine administration time rx enoxaparin mg ml mg sc once a day disp syringe refills oxycodone immediate release mg po q6h prn pain do not drive while taking narcotics hold rr rx oxycodone mg tablet by mouth every six hours disp tablet refills citalopram mg po qhs divalproex delayed release mg po bid quetiapine fumarate mg po qam quetiapine fumarate mg po qhs trazodone mg po qam trazodone mg po qhs discharge disposition extended care facility discharge diagnosis right tibia fracture and right fibula fracture discharge condition mental status confused always level of consciousness alert and interactive activity status out of bed with assistance to chair or wheelchair discharge instructions instructions after orthopaedic surgery you were in the hospital for orthopedic surgery it is normal to feel tired or washed out after surgery and this feeling should improve over the first few days to week resume your regular activities as tolerated but please follow your weight bearing precautions strictly at all times activity and weight bearing partial weight bearing right lower extremity in aircast boot medications please take all medications as prescribed by your physicians at discharge continue all home medications unless specifically instructed to stop by your surgeon do not drink alcohol drive a motor vehicle or operate machinery while taking narcotic pain relievers narcotic pain relievers can cause constipation so you should drink eight 8oz glasses of water daily and take a stool softener colace to prevent this side effect anticoagulation please take lovenox daily for 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 aircast boot must be left on until follow up appointment unless otherwise instructed 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 follow up please follow up with dr in the trauma clinic days post operation for evaluation please call to schedule appointment please follow up with your primary care doctor regarding this admission within weeks and for and any new medications refills physical therapy partial weight bearing right lower extremity in aircast boot treatments frequency dressing change as needed staples remain until follow up visit followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies no allergies adrs on file attending chief complaint abdominal pain found to have pericardial effusion major surgical or invasive procedure pericardiocentesis intubation bronchoscopy history of present illness this is a yom with a pmh significant for developmental mental delay seizure disorder and blindness who is being admitted to the ccu following pericardial drainage for a moderate to large pericardial effusion he lives a group home and he has been complaining of abdominal pain for about a week he went to his pcp who was unable to examine him due to agitation he then went to ed on with the same complaints and his vitals at the time were afebrile hr 110s 120s sbp 130s ra he was acutely agitated and required haldol mg im haldol mg iv ativan mg im and dilaudid mg iv he then got a ct abdomen to evaluate his abdominal pain and it showed a moderate to large pericardial effusion small bilateral pleural effusions and no significant intra abdominal process he then received a bedside echocardiogram that showed rv collapse he was given l ns and he was transferred to bid ed the ed here his bp was hr rr and room air labs significant for wbc poly lymph hgb inr k cr an echocardiogram the ed showed the ivc was non collapsible but the ra was not invaginating with diastole ekg showed nsr tachycardia with pr depression i ii elevation avr decreased voltages no electrical alternans he was acutely agitated and required intubation fentanyl versed he was then taken to the cath lab to have a pericardial drain placed but prior to the procedure his pulse was nonpalpable with a dropping bp and he required seconds of chest compressions with rosc he then received a pericardial drain without complications and ml of bloody fluid was drained he only received about ml of ivf the cath lab on arrival to the ccu t bp hr on volume controlled cmv with fio2 peep set rr set vt ml saturation he is on fentanyl and versed gtt past medical history blindness mental delay seizure disorder social history family history unknown physical exam admission vitals t bp hr on volume controlled cmv with fio2 peep set rr set vt ml saturation he is on fentanyl and versed gtt general intubated and sedated et tube place heent normocephalic atraumatic neck supple no appreciable jvp but difficult to tell cardiac tachycardia normal s1 s2 no m r g lungs mechanical breath sounds bilaterally no appreciable rales abdomen distended but soft without masses extremities cool arms non pitting edema bilateral lower extremities up to mid tibia skin no significant skin lesions or rashes pulses distal pulses palpable and symmetric access left ac and right ac discharge pertinent physical general nad awake heent normocephalic atraumatic neck supple no appreciable jvp but difficult to tell cardiac tachycardia normal s1 s2 no m r g lungs slight rales bilateral bases poor effort abdomen distended but soft without masses nttp extremities no pedal edema skin rashes from ekg leads on chest pulses distal pulses palpable and symmetric access none pertinent results admission labs 00pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00pm blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 00pm blood plt 00pm blood ptt 00pm blood glucose urean creat na k cl hco3 angap 45pm blood ck cpk 54am blood alt ast alkphos totbili 00pm blood ctropnt 45pm blood calcium phos mg 45pm blood tsh 11pm blood po2 pco2 ph caltco2 base xs intubat intubated comment peripheral 11pm blood lactate 11pm blood o2 sat 55pm blood freeca 59pm blood sed rate test cytology report final specimen s submitted pericardial fluid diagnosis pericardial fluid negative for malignant cells other pertinent labs 29pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 08am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 54am blood glucose urean creat na k cl hco3 angap 29pm blood caltibc vitb12 folate hapto ferritn trf 44pm blood caltibc vitb12 folate ferritn trf 29pm blood t4 t3 38am blood free t4 44pm blood free t4 28am blood anca negative b 29pm blood rheufac crp 59pm blood 38am blood crp 28am blood igg 56am blood c3 c4 28am blood hiv ab negative 21am blood type art po2 pco2 ph caltco2 base xs intubat intubated 30pm blood type art fio2 po2 pco2 ph caltco2 base xs 20pm blood lactate page of cytology report final specimen s submitted pericardial fluid collected diagnosis pericardial fluid negative for malignant cells blood only cytology report final specimen s submitted bronchial lavage diagnosis bronchial lavage negative for malignant cells bronchial epithelial cells and pulmonary macrophages a background of numerous inflammatory cells including neutrophils histiocytes and lymphocytes microbiology pm fluid other r o coxsackievirus types a and b enterovirus culture final no enterovirus isolated viral culture r o cytomegalovirus preliminary no cytomegalovirus cmv isolated cytomegalovirus early antigen test shell vial method final negative for cytomegalovirus early antigen by immunofluorescence refer to culture results for further information fluid culture final no growth anaerobic culture final no growth fungal culture preliminary no fungus isolated acid fast smear final no acid fast bacilli seen on direct smear acid fast culture preliminary no mycobacteria isolated pm blood culture source venipuncture final report blood culture routine final gemella species presumptive identification anaerobic bottle gram stain final reported to and read back by on at gram positive cocci clusters pm urine source catheter final report urine culture final no growth pm urine source catheter final report legionella urinary antigen final negative for legionella serogroup antigen reference range negative performed by immunochromogenic assay a negative result does not rule out infection due to other l pneumophila serogroups or other legionella species furthermore infected patients the excretion of antigen urine may vary pm sputum source endotracheal final report gram stain final pmns and epithelial cells 100x field per 1000x field gram positive cocci pairs and chains respiratory culture final heavy growth commensal respiratory flora am bronchoalveolar lavage bronchial lavage gram stain final per 1000x field polymorphonuclear leukocytes no microorganisms seen respiratory culture final no growth cfu ml legionella culture final no legionella isolated immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii fungal culture preliminary no fungus isolated nocardia culture preliminary no nocardia isolated acid fast smear final no acid fast bacilli seen on concentrated smear acid fast culture preliminary no mycobacteria isolated am bronchial washings bronchial wash gram stain final per 1000x field polymorphonuclear leukocytes no microorganisms seen respiratory culture final no growth cfu ml legionella culture final no legionella isolated nocardia culture preliminary no nocardia isolated acid fast smear final no acid fast bacilli seen on concentrated smear acid fast culture preliminary no mycobacteria isolated am rapid respiratory viral screen culture bronchial wash final report respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at within week if additional testing is needed respiratory viral antigen screen final less than columnar epithelial cells inadequate specimen for dfa detection of respiratory viruses interpret all negative dfa and or culture results from this specimen with caution negative results should not be used to discontinue precautions recommend new sample be submitted for confirmation refer to respiratory viral culture and or influenza pcr results listed under other tab for further information reported to and read back by at pm immunology cmv source line a final report cmv viral load final cmv dna not detected performed by cobas ampliprep cobas taqman cmv test linear range of quantification iu ml iu ml limit of detection iu ml this test has been verified for use the patient population am pleural fluid pleural fluid gram stain final per 1000x field polymorphonuclear leukocytes no microorganisms seen fluid culture final no growth anaerobic culture preliminary no growth acid fast smear final no acid fast bacilli seen on direct smear acid fast culture preliminary blood cultures no growth final urine cultures no growth final imaging tte the left atrium is normal size there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef the right ventricular cavity is unusually small with normal free wall contractility there is a large pericardial effusion the effusion appears circumferential stranding is visualized within the pericardial space c w organization the pericardium appears thickened there are no echocardiographic signs of tamponade no right atrial or right ventricular diastolic collapse is seen impression large circumferential pericardial effusion thickened parietal pericardium no echocardiographic evidence of tamponade normal lv function small rv cavity size with normal function cxr ap portable impression evidence for bilateral pleural effusions and consolidation or atelectasis the left lower lobe prominent cardiac silhouette tte due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded overall left ventricular systolic function is normal lvef right ventricular systolic function is significantly depressed the apical the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic stenosis there is a small moderate sized pericardial effusion the apical views the fluid is all echodense and there does appear to be tagging of the rv wall to the pericardium raising question of constriction those views the effusion is small all 0cm and the fluid is echodense the subcostal windows are quite limited but the posterolateral pocket may be a little bigger there measuring up to 3cm it is hard to make out whether any of that fluid is simple but i suspect it is also echodense like the rest of the pericardial fluid there are no echocardiographic signs of tamponade impression small to moderate sized echodense circumferential pericardial effusion pleural effusion no 2d echo evidence of tamponade depressed global right ventricular systolic function the images and the report from are not available for review cta chest impression no evidence of pulmonary embolism within limitations of the study limited by patient motion there is a large nonhemorrhagic pericardial effusion with pericardial drain place there is associated leftward interventricular septal bowing and contrast reflux into the hepatic veins suggestive of right ventricular strain bilateral nonhemorrhagic pleural effusions are larger compared to bilateral compressive atelectasis with collapse of the left lower lobe and posterior basal segment of the right lower lobe there is also linear atelectasis the left upper lobe cxr ap portable impression central pulmonary vascular congestion with new mild edema since the examination the lung volumes remain low unchanged pleural effusions and bibasilar atelectasis ct chest w contrast impression decrease size of pericardial effusion extensive mediastinal lymphadenopathy is unchanged the lymph nodes are borderline likely reactive large bilateral layering pleural effusions associated with adjacent atelectasis are stable no definitive new lung abnormalities are detected tte left ventricular wall thicknesses are normal the left ventricular cavity size is normal left ventricular systolic function is hyperdynamic ef right ventricular chamber size and free wall motion are normal there is a moderate sized pericardial effusion the effusion appears circumferential the effusion is echo dense consistent with blood inflammation or other cellular elements there are no echocardiographic signs of tamponade however the presence of a non free flowing pericardial effusion these signs may be absent despite impairment of right ventricular filling compared with the prior study images reviewed of the pericardial effusion is larger tte left ventricular wall thickness cavity size and global systolic function are normal lvef there is a small to moderate sized pericardial effusion the effusion appears circumferential the effusion is echo dense consistent with blood inflammation or other cellular elements there are no echocardiographic signs of tamponade however there is significant accentuated respiratory variation mitral tricuspid valve inflows consistent with impaired ventricular filling compared with the prior study images reviewed of the effusion appears smaller cxr impression compared to chest radiographs through previous pulmonary vascular congestion has resolved but moderate enlargement of the cardiac silhouette remains exaggerated by very low lung volumes there is no mediastinal venous engorgement to suggest elevated central venous pressure pleural effusions are likely but not large no pneumothorax discharge labs most recent since discharge 10am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 10am blood ptt 10am blood glucose urean creat na k cl hco3 angap 10am blood calcium phos mg brief hospital course mr is a y o man with history of developmental delay who presented to an osh with abdominal pain was found to have a large pericardial effusion on ct abd pelvis transferred to for further management pericardial effusion pericarditis patient initially presented with abdominal pain with finding of pericardial effusion as incidental finding unclear if symptoms are related to effusion however as patient with limited ability to express himself clearly due to developmental delay he underwent pericardiocentesis with findings consistent with inflammatory bloody output serial tte post procedure showed persistent but much improved and stable pericardial fluid as well as possible constrictive physiology he also had positive inflammatory markers crp esr extensive work up did not reveal clear etiology with work up negative for tb thyroid dysfunction malignancy and infection intrinsic to pericardial fluid most likely explanation would be that patient had pneumonia as below triggering para pneumonic pericarditis and effusion with subsequent heart failure as a result of effusion and possible constriction he was diuresed intermittently with lasix while the ccu and started on colchicine therapy for planned days he was evaluated by c surg and after discussion with patient s guardian mother and essential return to baseline functional status it was decided not to pursue any invasive procedures such as pericardial stripping vs window after evaluation and treatment with physical therapy he was discharged back to his home facility hypervolemia patient had low albumin constrictive physiology and lower extremity edema bilateral pleural effusions and elevated cvp on admission this was felt to be due to acute inflammation leading to low albumin and effusive constrictive physiology treated with lasix while the icu he was euvolemic at discharge off any maintenance diuretics pleural effusions given extensive work up detailed above patient was noticed to have large pleural effusions likely due to para pneumonic inflammation and volume overload he underwent u s guided drainage of his left sided effusion exudative without clear signs of infection with during this admission and improvement noted on subsequent imaging hcap patient was admitted with fever and pulmonary infiltrates and overall picture that was felt to be consistent with pneumonia he was treated with course of vancomycin cefepime azithro as such unfortunately only positive growth from bal and cultures from multiple sources was gamella from blood per id felt to be likely contaminant his respiratory status improved to baseline at time of discharge rash during this admission patient noted to have rash on back from b l shoulders to top of iliac crests diffuse erythematous plaques and papules with poorly demarcated borders covering most of back no sloughing vesicles or purpura blanchable nature this was felt to be possible heat rash or possible drug effect however no concerning findings c w sjs ten or significant eosinophilia on lab work this self resolved with mobilization from the bed prior to discharge hypoxic respiratory failure the patient was initially intubated and sedated prior to admission due to report of hypoxia and agitation which would have potentially complicated pericardial drainage he was found as above to have pneumonia pleural effusions pericardial effusion and atelectasis incomplete collapse of bilateral lower lobes cta chest also showed no signs of pe he was extubated with treatment of his multiple conditions as above on and quickly was weaned to room air prior to discharge bradycardia while intubated patient had multiple episodes of bradycardia with possible junctional rhythm never lasting more than seconds to a minute these were all felt to be vagal nature as they occurred the setting of bladder scan trach adjustment and ventilation changes he was monitor closely on tele without further episodes post discharge anemia baseline h h iron studies c w slight anemia of chronic disease has been low likely because of hemodilution the setting of ivf his h h improved with supportive care malnutrition he had low albumin possibly due to acute inflammation illness and prolonged intubation he did receive tube feeds while intubated and was quickly restarted on regular diet prior to discharge coagulopathy inr on admission today unknown etiology malnutrition liver dysfunction medication induced this was most likely due to malnutrition and vitamin k dysfunction as inr improved quickly after initiation of nutrition seizures chronic continued on home depakote mg bid developmental delay behavioral issues chronic continued during hospitalization on home seroquel trazodone and celexa transitional issues colchicine for month course for possible pericarditis day outpatient cards f u weeks repeat tte weeks before cardiology appointment to assess for pericardial fluid reaccumulation decision made not to pursue pericardial stripping vs pericardial window placement given ability to return to baseline functional status can consider the future if recurrent pericardial effusion during work up for cause of pericardial effusion patient had negative quantiferon gold assay for tb code status full code contact mother medications on admission the preadmission medication list is accurate and complete quetiapine fumarate mg po qhs divalproex delayed release mg po bid citalopram mg po daily quetiapine fumarate mg po qam trazodone mg po qhs trazodone mg po qam vitamin d unit po daily multivitamins w minerals tab po daily oyster shell calcium calcium carbonate mg calcium mg oral daily sodium fluoride dental gel appl tp bid discharge medications colchicine mg po bid duration days please continue for days day rx colchicine mg tablet s by mouth twice a day disp tablet refills citalopram mg po daily divalproex delayed release mg po bid multivitamins w minerals tab po daily oyster shell calcium calcium carbonate mg calcium mg oral daily quetiapine fumarate mg po qam quetiapine fumarate mg po qhs sodium fluoride dental gel appl tp bid trazodone mg po qhs trazodone mg po qam vitamin d unit po daily discharge disposition home discharge diagnosis primary diagnosis pericarditis pericardial effusion health care associated pneumonia pleural effusion hyperkalemia hypoxic respiratory failure secondary diagnoses developmental delay seizure disorder discharge condition mental status confused sometimes at baseline the patient is aox1 and he has returned to baseline on discharge level of consciousness alert and interactive activity status ambulatory independent patient is legally blind so requires assistance at baseline discharge instructions dear mr you came to because you were having stomach pain and it was discovered that you had fluid around your heart what was found the hospital your had fluid around your heart called a pericardial effusion your had fluid your lungs called a pleural effusion you had an infection your lungs called pneumonia you had high levels of potassium your blood called hyperkalemia you had difficulty breathing and were on a mechanical ventilator for week what was done for you the hospital the fluid around your heart was causing problems with pumping you went to the catheterization lab a drain was placed to remove fluid after two days most of the fluid was gone and the drain was pulled out the fluid was sent for laboratory studies to look for a cause like infection or disease but no cause was found we continued to monitor your heart with pictures transthoracic echocardiograms and chest xrays you were given oral medications to keep the combat the inflammation around your heart the fluid did not reaccumulate and you are safe to go home with follow up with your doctor samples of the fluid your lungs were taken by two methods the first was a bronchoscopy where a tube with a video camera was placed down your throat to look inside your lungs the second method was a pleurocentesis where a needle was put your side and the fluid was pulled off these samples were sent to the laboratory for studies to look for a cause we found indicators of infection but no specific bacterium that was likely to cause it you had chest x rays to watch for reaccumulation and that did not happen for your infection you were see by specialists from the infectious diseases and pulmonary divisions you most likely had a pneumonia you received antibiotics for several days you had a fever with this infection you received acetaminophen you had your intake and output monitored to make sure you did not become dehydrated your symptoms improved and you are safe to go home initial laboratory studies showed that you had high levels of potassium your blood you received fluids and diuresis at different points during your hospitalization you had frequent electrocardiograms and laboratory studies to monitor for effects of high potassium your potassium level returned to normal you came to on a mechanical ventilator to help your breathing while you were sick you were on the ventilator for several days you showed us you could breathe on your own so we stopped the ventilator and you were able to breathe on your own you did not require re intubation what should you do when you go home for the fluid around the heart you should take a new medicine called colchicine described below follow up with your primary care doctor ask your primary care doctor to schedule follow up appointment and transthoracic echocardiogram with a cardiologist new medications colchicine mg by mouth the morning and at night every day this medication is for your pericarditis you should take it for months last dose otherwise you can continue taking the medications you had taken at home before coming to the hospital followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies diflucan attending chief complaint dyspnea major surgical or invasive procedure none history of present illness history of present illness ms is a year old woman with history of dysfunctional uterine bleeding iron deficiency anemia and polysubstance abuse including crack cocaine presenting with chest pain notably she was seen the ed on for chest and abdominal pain worsened with inspiration she underwent ct abd pelvis and was diagnosed with a right lower lobe pneumonia based on that ct and was discharged on azithromycin she initially felt better but then the day prior to this admission developed left sided chest pressure constant worse with deep breathing she also reported dyspnea on exertion she denied any nausea vomiting diaphoresis or exertional component to the pain she denied any unilateral leg pain history of blood clots or recent surgeries she did report a flight to weeks prior hours she is a daily smoker not on ocps in the ed initial vital signs were notable for ra labs were notable for d dimer trop bnp lactate hb has been since studies performed include cta chest segmental and subsegmental pulmonary emboli in the lingula right middle lobe and bilateral lower lobes upper lobes are not particularly well assessed due to motion no evidence of right heart strain findings compatible with a pulmonary infarct in the lingula areas of atelectasis at the lung bases with suspected right basilar infarct as well small right and trace left pleural effusions the rounded cm lesion in the upper and slightly outer right breast which likely correlates with lesion worked up by prior ultrasound in patient was given po acetaminophen mg po ibuprofen mg ivf ns ml iv heparin unit iv heparin started units hr po ibuprofen mg upon arrival to the floor patient reports story as above she reports continued left chest pain with inspiration and dyspnea with activity but this has improved since initiation of the heparin gtt she notes dysfunctional uterine bleeding and a history of anemia we discussed blood transfusion given hb although i relayed that this is chronic and she does not need urgent transfusion at this time she preferred to think about it overnight review of systems complete ros obtained and is otherwise negative past medical history pmh hypertension genital herpes fatty liver by ultrasound study psh s p c section x and s p multiple myomectomy for fibroids in social history family history her family history is noted for hyperlipidemia and father living age and diabetes in her mother living age physical exam admission physical exam vitals 2po 98ra general alert and interactive heent ncat cardiac regular rhythm normal rate lungs clear to auscultation bilaterally abdomen normal bowels sounds non distended non tender extremities no clubbing cyanosis or edema no palpable cords skin warm no rash neurologic cn2 intact aox3 discharge physical exam vitals hr data last updated temp pt refused v s tm bp hr rr o2 sat o2 delivery ra wt lb kg general alert and interactive heent ncat cardiac regular rhythm normal rate lungs clear to auscultation bilaterally abdomen normal bowels sounds non distended non tender extremities no clubbing cyanosis or edema no palpable cords skin warm no rash neurologic cn2 intact aox3 pertinent results admission labs 08am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 08am blood glucose urean creat na k cl hco3 angap 08am blood 08am blood ctropnt 08am blood probnp 08am blood iron 08am blood caltibc ferritn trf 12am blood lactate discharge labs 35am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 35am blood glucose urean creat na k cl hco3 cxr impression perhaps minimal residual opacity at the right costophrenic angle as seen on prior ct no new consolidation chest cta impression segmental and subsegmental pulmonary emboli in the lingula right middle lobe and bilateral lower lobes upper lobes are not particularly well assessed due to motion no evidence of right heart strain findings compatible with a pulmonary infarct in the lingula areas of atelectasis at the lung bases with suspected right basilar infarct as well small right and trace left pleural effusions the rounded cm lesion in the upper and slightly outer right breast which likely correlates with lesion worked up by prior ultrasound in tte impression lvef mild symmetric left ventricular hypertrophy with normal cavity size and regional global biventricular systolic function mild mitral regurgitation mild pulmonary hypertension brief hospital course ms is a year old woman with history of dysfunctional uterine bleeding iron deficiency anemia and polysubstance abuse including crack cocaine presenting with chest pain found to have a pulmonary embolism non submassive pe pt presented with a week of worsening dyspnea and left sided chest pain chest cta notable for segmental pe in lingual rml b l lower lobes with pulmonary infarct in lingual and suspected r basilar infarct she was hemodynamically stable tte was obtained lvef there was no e o r heart strain but tte notable for mild symmetric lvh with regional biventricular function mild mitral regurg and mild pulm htn risk factors include smoking cig day recent hr flight from she was started on a hep gtt and transitioned to po eliquis 10mg bid x7 days followed by 5mg bid for her pain she was given standing tylenol q8h prn ibuprofen dysfunctional uterine bleeding iron deficiency anemia reports hgb since im the setting of fibroids and dysfunctional uterine bleeding she has undergone intermittent iron infusions this admission hb baseline with most recent ferritin in her hgb was on but she was asymptomatic previously she repeatedly refused blood transfusions but was amenable to receiving 1u prbc prior to being discharged she was adamant about being discharged on as she had to go home to take care of her two younger boys she indicated she would present to the ed if she noticed any active bleeding or become symptomatic she has an outpatient obgyn appointment on and said she would contact her pcp for an appointment polysubstance use pt with active etoh use drinker daily and daily crack cocaine inhalation she was seen by addiction psychiatry in started on acamprosate and referred to social work she stopped taking this medication and missed her most recent social work appointment sw was initially consulted however pt did not seem amenable to meeting with them she denied any illicit drug use after admission will suggest she f u with outpatient pcp psychiatry regarding substance use medication changes started eliquis 10mg bid x7 days last day followed by 5mg bid transitional issues re check h h at next clinic visit within week of discharge continue to monitor for active bleeding she has a f u scheduled with obgyn on please assess for vaginal bleeding at that time as she was recently started on eliquis for pe she denied a history of polysubstance abuse during this admission please re address possible illicit drug use either with pcp or consider egd to evaluate for anastamosis colonoscopy for fe deficiency anemia s p roux en y bypass consider multivitamin fe supplements b12 vitamin d and calcium supplementation contact husband on admission the preadmission medication list is accurate and complete this patient is not taking any preadmission medications discharge medications acetaminophen mg po q8h rx acetaminophen mg two tablet s by mouth every hours as needed for pain disp tablet refills apixaban mg po bid take 10mg twice daily for a total of days until then 5mg twice daily thereafter rx apixaban eliquis mg one tablet s by mouth twice daily disp tablet refills ibuprofen mg po q8h prn pain mild rx ibuprofen mg one tablet s by mouth every hours as needed for pain disp tablet refills discharge disposition home discharge diagnosis pulmonary embolism iron deficiency anemia polysubstance use 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 privilege caring for you at why was i in the hospital you were in the hospital for a blood clot in your lungs what happened to me in the hospital you received blood for your anemia we gave you an iv blood thinner for your lung clot called heparin we switched this to oral tablets called eliquis apixaban what should i do after i leave the hospital continue to take all your medicines and keep your appointments you are now on a blood thinner that increases your risk of bleeding please go to your nearest emergency department if you experience any of the following vaginal bleeding or bleeding elsewhere chest pain palpitations rapid heart beats shortness of breath lightheadedness please follow up with your primary care doctor within days of being discharged you will need to continue taking the eliquis apixaban for your lung clot take your eliquis apixaban as directed take 10mg in the morning 10mg in the evening for a total of days take 5mg in the morning 5mg in the evening we wish you the best sincerely your team followup instructions

name unit no admission date discharge date date of birth sex f service obstetrics gynecology allergies diflucan attending chief complaint vaginal bleeding major surgical or invasive procedure none history of present illness patient is a y o g6p2 with a history of known fibroid uterus history of anemia history of pe on eliquis who presents with vaginal bleeding lmp started has been much heavier than her prior periods changing more than one pad per hour having dizziness palpitations sob as well mild cramping she is followed by dr office for her fibroid uterus started lupron test dose first dose mg with plan for q3 month injections had been advised to get ferraheme injections for anemia baseline hct but did not keep appointments she underwent an endometrial biopsy in which returned as proliferative endometrium and benign endocervix patient states she has discussed hysterectomy with dr but was waiting for her blood counts to come up past medical history ob history tab x ltcs x gyn history lmp last pap smear nilm hpv fibroid uterus as per above pmh anemia fatty liver pe on eliquis surgical history prim ltcs open mmy rpt ltcs laparoscopic hiatal hernia repair roux en y loa social history family history no history of ovarian uterine breast or colon cancer physical exam vitals stable and within normal limits general nad comfortable cv rrr lungs ctab abdomen soft non distended non tender uterus palpable cm above umbilicus gu pad with minimal spotting extremities no edema no ttp pneumoboots in place bilaterally pertinent results 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 02am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 35am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 25am blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 00am blood glucose urean creat na k cl hco3 angap brief hospital course on ms was admitted to the gynecology service after presenting with vaginal bleeding secondary to known fibroid uterus with possible additional lupron effect her hct on initial presentation was on hd she received units packed rbcs with a rise in her hct to she was also started on provera mg daily was consulted and planned for uterine artery embolization on hd her hct was and she received an additional two units packed rbcs with appropriate response of her hematocrit to and subjective improvement in her symptoms her provera was also increased to mg twice daily by hd she had minimal ongoing vaginal bleeding and was overall feeling better she elected to defer uae during this admission and requested to be discharged home her foley catheter was removed and she voided spontaneously she had minimal pain was ambulating independently and continued on regular diet she was discharged home in stable condition with outpatient follow up scheduled medications on admission apixaban mg po bid discharge medications acetaminophen mg po q6h prn pain mild fever medroxyprogesterone acetate mg po bid rx medroxyprogesterone provera mg tablet s by mouth twice a day disp tablet refills apixaban mg po bid discharge disposition home discharge diagnosis vaginal bleeding secondary to known fibroid uterus discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms you were admitted to the gynecology service to manage your vaginal bleeding you have recovered well and the team believes you are ready to be discharged home please call dr office with any questions or concerns please follow the instructions below general instructions take your medications as prescribed you may eat a regular diet call your doctor for fever 4f severe abdominal pain difficulty urinating vaginal bleeding requiring pad hr abnormal vaginal discharge nausea vomiting where you are unable to keep down fluids food or your medication chest pain headache or difficulty breathing to reach medical records to get the records from this hospitalization sent to your doctor at home call 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 symptomatic fibroid uterus major surgical or invasive procedure total abdominal hysterectomy bilateral salpingectomy history of present illness is a gravida who returns to discuss further future hysterectomy and bilateral salpingectomy on endometrial biopsy showed proliferative endometrium and benign endocervix she has a history of an enlarged uterus excessive uterine bleeding and chronic acute blood loss anemia for which she has received iv iron therapy in addition in efforts to decrease her uterine fibroid burden and decrease her excessive bleeding she has been on im lupron therapy since initiating lupron therapy she has had no further vaginal bleeding she will get a month dose today she has a history of thrombosis pulmonary embolism and has been treated with eliquis she has an appointment with dr heme onc for recommendations in regard to perioperative anticoagulation therapy past medical history ob history tab x ltcs x gyn history lmp last pap smear nilm hpv fibroid uterus as per above pmh anemia fatty liver pe on eliquis surgical history prim ltcs open mmy rpt ltcs laparoscopic hiatal hernia repair roux en y loa social history family history no history of ovarian uterine breast or colon cancer physical exam on day of discharge pertinent results 25am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt brief hospital course on ms was admitted to the gynecology service after undergoing the procedures listed below please see the operative report for full details her post operative course was uncomplicated immediately post op her pain was controlled with iv dilaudid and a tap block she was transitioned to lovenox hours post operatively given her history of provoked pe on post operative day her urine output was adequate so her foley was removed and she voided spontaneously her diet was advanced without difficulty and she was transitioned to po oxycodone tylenol by post operative day she was tolerating a regular diet voiding spontaneously ambulating independently and pain was controlled with oral medications she was then discharged home in stable condition with outpatient follow up scheduled medications on admission apixaban 5mg bid leuprolide discharge medications acetaminophen mg po q6h prn pain mild fever do not exceed 4000mg in hrs rx acetaminophen mg tablet s by mouth every six hours disp tablet refills apixaban mg po bid rx apixaban eliquis mg tablet s by mouth two times per day disp tablet refills docusate sodium mg po bid hold for loose stools rx docusate sodium mg capsule s by mouth twice per day disp capsule refills oxycodone immediate release mg po q4h prn pain moderate cause sedation do not drink or drive rx oxycodone mg tablet s by mouth every four hours disp tablet refills discharge disposition home discharge diagnosis fibroid uterus discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions ms were admitted to the gynecology service after your procedure have recovered well and the team believes are ready to be discharged home please call dr office with any questions or concerns please follow the instructions below general instructions take your medications as prescribed do not drive while taking opioids e g oxycodone hydromorphone take a stool softener such as colace while taking opioids to prevent constipation do not combine opioid and sedative medications or alcohol do not take more than 4000mg acetaminophen apap in hrs no strenuous activity until your post op appointment nothing in the vagina no tampons no douching no sex for weeks no heavy lifting of objects lbs for weeks may eat a regular diet may walk up and down stairs incision care may shower and allow soapy water to run over incision no scrubbing of incision no tub baths for weeks leave the steri strips in place they will fall off on their own if they have not fallen off by days post op may remove them if have staples they will be removed at your follow up visit call your doctor for fever 4f severe abdominal pain difficulty urinating vaginal bleeding requiring pad hr abnormal vaginal discharge redness or drainage from incision nausea vomiting where are unable to keep down fluids food or your medication constipation drink liters of water every day incorporate to grams of fiber into your daily diet to maintain normal bowel function examples of high fiber foods include whole grain breads bran cereal prune juice fresh fruits and vegetables dried fruits such as dried apricots and prunes legumes nuts seeds take colace stool softener times daily use dulcolax suppository daily as needed take miralax laxative powder daily as needed stop constipation medications if are having loose stools or diarrhea to reach medical records to get the records from this hospitalization sent to your doctor at home call followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies penicillins amiodarone attending chief complaint neutropenic fever major surgical or invasive procedure none history of present illness w cad afib coumadin gerd and dx of pleural mesothelioma s p cycle two of pemetrexed at primary oncologist dr who presents with several day history of fatigue malaise dry cough myalgias over the past week with tmax of he received his most recent dose of pemetrexed on after receiving treatment he experienced several days of myalgias and malaise he experienced similar symptoms during his initial chemotherapy regimen however was able to recover after days however after this dose of pemetrexed the symptoms the symptoms have lasted longer he has experienced night sweats and chills the night prior to presentation also has experienced dry cough over the last two days also experienced rhinorrhea has had a persistent left sided pleuritic chest pain that has worsened over the past week denies sores throat nausea vomiting diarrhea dysuria rash or joint pains denies headache or neck stiffness does note that a family member he interacted with last week has since down with a sore throat mr was diagnosed with pleural mesothelioma after being admitted from to for progressive dyspnea on exertion over a month period at that time patient underwent pleuroscopy thorascopy and talc pleurodesis pleural biopsy was performed at that time which showed malignant mesothelioma epitheliod type with cytology of pleural effusion positive for mesothelioma he was referred to for mesothelioma treatment he initially was seen by dr surgical consideration however he was deemed not a surgical candidate and subsequently was transferred to dr they had discussed palliative treatment with pemetrexed to assess whether mesothelioma would be improved if mesothelioma did not improve plan was to stop chemotherapy and transition to comfort measures in the ed initial vs were ra labs were notable for neutropenia to anc lactate inr imaging included cxr results below treatments received 1l ns ciprofloxacin mg iv once clindamycin mg iv once on arrival to the floor patient is in no discomfort resting comfortably he is interested in eating food review of systems as per hpi otherwise negative past medical history past oncologic history mr was diagnosed with pleural mesothelioma after being admitted from to for progressive dyspnea on exertion over a month period at that time patient underwent pleuroscopy thorascopy and talc pleurodesis pleural biopsy was performed at that time which showed malignant mesothelioma epitheliod type with cytology of pleural effusion positive for mesothelioma he was referred to for mesothelioma treatment he initially was seen by dr surgical consideration however he was deemed not a surgical candidate and subsequently was transferred to dr they had discussed palliative treatment with pemetrexed to assess whether mesothelioma would be improved if mesothelioma did not improve plan was to stop chemotherapy and transition to comfort measures past medical history anxiety atrial fibrillation s p pvi ablation on coumadin benign prostatic hypertrophy constipation coronary artery disease gastroesophageal reflux hypertension hypothyroidism lower extremity edema hip fracture sensorineural hearing loss seborrheic keratosis basal cell carcinoma actinic keratosis gallbladder polyp pleural effusion s p multiple thoracenteses pleural meothelioma social history family history mother heart problems pacemaker placement father lung cancer non smoker sister living alzheimer s disease mgm deceased cancer died early physical exam admission physical exam vs on ra general pleasant appearing does not appear in any acute distress sitting in bed comfortably heent eomi posterior pharynx is non erythematous no lymphadenopathy no oral ulcers or mucositis cardiac irregularly irregular rhythm normal s1 s2 minimal murmur at right upper sternal border lung crackles at left lower lobe about up the lung fields minimal crackles at right lower lobe no wheezes abd soft non tender non distended no rebound or guarding normoactive bowel sounds ext right lower extremity swelling with chronic venous changes on anterior shins surgical scar of right knee neuro a o x cn ii xii intact skin numerous seborrheic keratosis discharge physical exam vs 99ra general sitting in chair appears comfortable heent ncat mmm eomi cardiac irregularly irregular rhythm normal s1 s2 murmur at rusb lung mildly diminished bs over l lung fields in comparison to r otherwise clear to auscultation abd soft non tender non distended no rebound or guarding ext rle edema with chronic venous changes on anterior shin surgical scar of right knee neuro a o x cn ii xii intact skin numerous seborrheic keratosis pertinent results admission labs 03am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 03am blood neuts bands monos eos baso myelos nrbc absneut abslymp absmono abseos absbaso 03am blood hypochr occasional anisocy occasional poiklo macrocy occasional microcy occasional polychr occasional ovalocy ellipto occasional 03am blood ptt 03am blood glucose urean creat na k cl hco3 angap 03am blood calcium phos mg 16am blood lactate 37pm urine color yellow appear clear sp 37pm urine blood tr nitrite neg protein neg glucose neg ketone neg bilirub neg urobiln ph leuks neg 37pm urine rbc wbc bacteri few yeast none epi 37pm urine mucous rare discharge labs 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 00am blood ptt 00am blood glucose urean creat na k cl hco3 angap 00am blood calcium phos mg micro blood cx ngtd x2 urine cx negative imaging cxr vague opacity projecting over the left mid lung which is new since prior but may be due to known underlying mesothelioma as opposed to new underlying parenchymal process although this would be difficult to exclude entirely unilat lower ext veins no evidence of deep venous thrombosis in the right lower extremity veins note is made of slow flow in the calf veins requiring power doppler analysis to demonstrate flow brief hospital course mr is an year old man w cad afib coumadin gerd and dx of pleural mesothelioma s p cycle two of pemetrexed at primary oncologist dr who p w several day history of fatigue malaise dry cough myalgias over the past week with tmax of pneumonia febrile neutropenia on admission patient found to have wbc anc corresponding to nadir after chemotherapy with a tmax of on evaluation cxr showed possible left lower lobe opacity along with the cough and rhinorrhea and recent sick contact this made pneumonia a possibility and so patient was started on vanc cefepime patient denied other localizing symptoms including that of gu and gi systems ucx was negative patient remained afebrile for remainder of hospital stay and was discharged on po levofloxacin to complete a total day course for pneumonia end date notably patient was monitored until appeared to be increasing for two consecutive days pleuritic chest pain likely related to underlying pneumonia versus mesothelioma low likelihood of pulmonary embolus as patient currently on anticoagulation and not tachycardic tachypneic ultrasound of rle negative for dvt pleuritic cp resolved after starting abx atrial fibrillation continued warfarin and sotalol pt s inr rose quickly while on home dose of warfarin on discharge dose decreased from 2mg daily to mg daily inr on discharge was next inr to be drawn on lower extremity swelling patient has history of r tkr c b hemarthrosis and subsequent chronic rle edema r was negative for dvt mesothelioma currently on palliative pemetrexed followed by dr anxiety continued home sertraline mg daily and alprazolam qhs prn bph continued finasteride mg daily levothyroxine continued home mcg days week transitional issues pt is to complete day course of levofloxacin for pneumonia end date pt s inr rose quickly while on home dose of warfarin dose decreased from 2mg daily to mg daily next inr to be drawn on pt noted that his quality of life in the hospital is poor and would not want to undergo further chemotherapy if it caused repeated admissions accordingly he plans to discuss utility of future chemotherapy with oncologist after discharge pt is to have repeat cbc drawn on at next oncology f u appt code status dnr dni emergency contact daughter medications on admission the preadmission medication list is accurate and complete finasteride mg po daily acetaminophen mg po q8h prn fever or pain alprazolam mg po qhs prn insomnia sotalol mg po bid warfarin mg po daily16 bifidobacterium infantis mg oral daily atorvastatin mg po qpm omeprazole mg po daily loratadine mg po daily sertraline mg po daily levothyroxine sodium mcg po 6x week folic acid mg po daily vitamin d unit po daily discharge medications acetaminophen mg po q8h prn fever or pain alprazolam mg po qhs prn insomnia atorvastatin mg po qpm finasteride mg po daily folic acid mg po daily levothyroxine sodium mcg po 6x week loratadine mg po daily omeprazole mg po daily sertraline mg po daily sotalol mg po bid vitamin d unit po daily warfarin mg po daily16 bifidobacterium infantis mg oral daily levofloxacin mg po q24h rx levofloxacin mg tablet s by mouth daily disp tablet refills discharge disposition home discharge diagnosis primary neutropenic fever healthcare associated pneumonia secondary discharge condition discharge condition stable mental status aox3 ambulatory status at discharge independent discharge instructions dear mr you were admitted to the for fever unfortunately we did not identify a clear source however your chest x ray was convincing for pneumonia and for that you were treated with antibiotics you will need to complete the antibiotic course total days end date listed below your inr was also elevated due to the antibiotics so your coumadin dose was decreased to 5mg daily and you will need to have your inr re drawn on it was a pleasure taking part in your care your team followup instructions

name unit no admission date discharge date date of birth sex m service orthopaedics allergies percocet motrin crab and lobster shellfish derived attending chief complaint back pain major surgical or invasive procedure l5 s1 alif l4 s1 plf history of present illness patient returns to the office for follow up since his last visit he states his back pain has gotten worse he has a known l5 s1 spondylolysis from a previous back injury he was doing well with si joint injections and lumbar esi he has pain with increase activity the is experiencing more leg pain and discomfort he had an mri showing lumbar spodylosis stable if not worse spondylolysis at l5 s1 his pain shoots down lateral aspects of his legs he denies any weakness or paresthesias he has tried all forms of therapy without relief past medical history high blood pressure asthma depression and arthritis social history family history noncontributory physical exam general appearance in no acute distress well developed well nourished neck thyroid neck supple full range of motion no cervical lymphadenopathy skin warm and dry heart no murmurs regular rate and rhythm s1 s2 normal lungs clear to auscultation bilaterally abdomen normal bowel sounds present soft nontender nondistended musculoskeletal cervical spine normal full range of motion lumbosacral spine normal no swelling or deformity extremities gross motor strength is intact in terms of deltoid biceps triceps wrist extension flexion finger extension flexion and intrinsics no clubbing cyanosis or edema postop general nad aao x3 lying awake in bed skin warm dry no rash cv rrr s1 and s2 nl pulm normal effort lungs are clear abd soft nt nd bs wound c d i no swelling redness or warmth extremities calves are soft no edema neurologic perrl face symmetrical speech clear and fluent tongue ml eoms intact negative pronator drift normal tone and bulk universally motor strength delt bi tri br wf we hi right left ip quad ham ta gas right left sensation intact to light touch brief hospital course patient was admitted to orthopedic spine service on and underwent the above stated procedure s on consecutive days patient tolerated the procedures well without complication please review dictated operative report for details patient was extubated without incident and was transferred to pac u then floor in stable condition during the patient s course were used for postoperative dvt prophylaxis intravenous antibiotics were continued for 24hrs postop per standard protocol initial postop pain was controlled with oral and iv pain medication diet was advanced as tolerated foley was removed in routine fashion and patient voided without incident lumbar epidural catheter was removed on pod hemovac was removed in routine fashion once the output per hours became minimal physical therapy and occupational therapy were consulted for mobilization oob to ambulate and adl s hospital course was otherwise unremarkable now day of discharge patient is afebrile vss and neuro intact with improvement in sciatica patient tolerated a good oral diet and pain was controlled on oral pain medications patient ambulated without issues patient s wound is clean dry and intact patient noted improvement in radicular pain patient is set for discharge to home in stable condition medications on admission the preadmission medication list is accurate and complete acetaminophen mg po q6h prn pain mild fever gabapentin mg po tid alprazolam mg po daily prn anxiety melatonin mg oral qhs prn insomnia pantoprazole mg po q24h paroxetine mg po daily discharge medications cyclobenzaprine mg po q8h rx cyclobenzaprine mg tablet s by mouth three times a day disp tablet refills docusate sodium mg po bid constipation hydromorphone dilaudid mg po q4h prn pain moderate rx hydromorphone mg tablet s by mouth q4 6h disp tablet refills senna mg po bid prn constipation first line acetaminophen mg po q6h prn pain mild fever alprazolam mg po daily prn anxiety gabapentin mg po tid melatonin mg oral qhs prn insomnia pantoprazole mg po q24h paroxetine mg po daily discharge disposition home discharge diagnosis lumbar spondylolisthesis lumbar spondylolysis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions lumbar decompression with fusion you have undergone the following operation lumbar decompression with fusion follow up appointments after you are discharged from the hospital and settled at home or rehab please make sure you have two appointments week post operative wound check visit after surgery a post operative visit with your surgeon for weeks after surgery you can reach the office at and ask to speak with your surgeon s surgical coordinator staff to schedule or confirm your appointments wound care if not already done in the hospital remove the incision dressing on day after surgery you may shower day after surgery starting on this day you should gently cleanse the incision and surrounding area daily with mild soap and water patting it dry when you are finished some swelling and bruising around the incision is normal your muscles have been cut separated and sewn back together as part of your surgical procedure you will leave the hospital with back discomfort from the surgical incision as you become more active and the incision and muscles continue to heal the swelling and pain will decrease have someone look at the incision daily for weeks call the surgeon s office if you notice any of the following increased redness along the length of the incision increased swelling of the area around your incision drainage from the incision weakness of your extremities greater than before surgery loss of bowel or bladder control development of severe headache leg swelling or calf tenderness fever above do not soak or immerse your incision in water for month for example no tub baths swimming pools or jacuzzi activity guidelines you may be given a rigid brace that you will wear whenever sitting up standing or walking you will wear it for weeks after surgery see the last page of these instructions for details on wearing the brace avoid strenuous activity bending pushing or holding your breath for example do not vacuum wash the car do large loads of laundry or walk the dog until your follow up visit with your surgeon avoid heavy lifting do not lift anything over pounds for the first few weeks that you are home from the hospital increase your activities a little each day walking is good exercise plan rest periods and try to avoid hills if possible remember exercise should not increase your back pain or cause leg pain reaching when you have to reach things on or near the floor always squat bending the knees rather than bending over at the waist lying down when lying on your back you may find that a pillow under the knees is more comfortable when on your side a pillow between the knees will help keep your back straight sitting should be limited to minutes at a time for the first week slowly increase the amount of sitting time remembering that it should not increase your back pain stairs use stairs only once or twice a day for the first week or as directed by the surgeon climb steps one at a time placing both feet on the step before moving to the next one driving you should not drive for weeks after surgery you should discuss driving with your surgeon nurse practitioner physician you may ride in a car for short distances when in the car avoid sitting in one position for too long if you must take long car rides do not ride for more than minutes without taking a break to stretch walk for several minutes and change position sexual activity you may resume sexual activity weeks after surgery avoiding pain or stress on the back reduction in symptoms patients who have experienced back and radiating leg pain for a short window of time before surgery should anticipate a significant decrease in pre operative symptoms if the pain has been present for a longer period months to years the pre operative symptoms will recover on a more gradual basis week by week it is not practical to expect immediate relief of symptoms routinely pain will gradually improve on a weekly basis weakness on a monthly basis and numbness in a range of months to year physical therapy outpatient physical therapy if appropriate will not begin until after your post operative visit with your surgeon a prescription is needed for formal outpatient therapy you may be given simple stretching exercises or a prescription for formal outpatient physical therapy based on what your needs are after surgery medications you will be given prescriptions for pain medications and stool softeners upon discharge from the hospital pain medications should be taken as prescribed by your surgeon or nurse practitioner physician you are allowed to gradually reduce the number of pills you take when the pain begins to subside if you are taking more than the recommended dose please contact the office to discuss this with a practitioner medication may need to be increased or changed constipation pain medications narcotics may cause constipation it is important to be aware of your bowel habits so you develop severe constipation that cannot be treated with simple over the counter laxatives most prescription pain medications cannot be called into the pharmacy for renewal the following are options you may explore to obtain a renewal of your narcotic medications call the office days before your prescription runs out and speak with office staff about mailing a prescription to your home pharmacy prescriptions will not be sent by fed ex ups call the office hours in advance and speak with our office staff about coming into the office to pick up a prescription if you continue to require medications you may be referred to a pain management specialist or your medical doctor for ongoing management of your pain medications avoid nsaids for weeks post operative these medications include but are not limited to the following non steroidal anti inflammatory drugs advil aleve cataflam clinoril diclofenac dolobid feldene ibuprofen indocin medipren motrin nalfon naprosyn nuprin relafen rufen tolectin toradol trilisate voltarin blood clots in the leg it is not uncommon for patients who recently had surgery to develop blood clots in leg veins symptoms include low grade fever and or redness swelling tenderness and or an aching cramping pain in your calf you should call your doctor immediately if you have these symptoms to prevent blood clots in legs try walking and or pumping ankles several times during the day if the blood clot breaks free from the leg vein it can travel to the lungs and cause severe breathing difficulty and or chest pain if you experience this call immediately questions any questions may be directed to your surgeon or physician during normal business hours 30am 00pm you can call the office directly at turn around time for a phone call is hours after normal business hours you can call the on call service and we will get back to you the next business day if you are calling with an urgent medical issue please tell the coordinator that it is an urgent issue and needs to be discussed in less than hours i e pain unrelieved with medications wound breakdown infection or new neurological symptoms lumbar corset or tlso brace guidelines you may have been given a rigid brace that you will wear for weeks after surgery you should put on your brace as you have been instructed by the orthotist brace maker instructions will be reviewed in the hospital by the nursing staff and physical therapist it is a good idea to start practicing with your brace before surgery putting it on taking it off sitting standing walking and climbing steps with the brace so you can assist with your post operative care in the hospital keep the name and phone number of the person who fitted and dispensed your brace close by in case you need to have the brace checked and or adjusted you should always have a barrier between your surgical incision and the brace for example you may want to put on a light t shirt and then the brace before getting dressed for the day during periods of rest take off the brace and expose the incision to the air by lying on your side for a few hours this will reduce the chance of your wound breaking down the brace must be worn at all times with the following exceptions lying flat in bed during a rest period or at night to sleep getting out of bed at night to go to the bathroom returning to bed immediately when you are finished showering you may wish to use a shower chair to help prevent bending twisting while bathing you should have someone help wash your back and legs followup instructions

name unit no admission date discharge date date of birth sex f service surgery allergies penicillins sulfa sulfonamide antibiotics attending chief complaint abdominal pain major surgical or invasive procedure diagnostic laparoscopy and open appendectomy history of present illness woman with day history of abdominal pain which was generalized and ultimately today had started to localize to the right lower quadrant she was anorexic but had no nausea vomiting fever or chills she had focal tenderness to palpation in the right lower quadrant on examination and on ct scan had a mm appendix in the right lower quadrant with significant surrounding inflammation and secondary inflammation of the terminal ileum past medical history none social history family history nc physical exam on discharge ra general comfortable regular rate and rhythm pulm no respiratory distress abdomen soft nontender midline staples in tact extremities warm and well perfused pertinent results 58am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 15pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 38pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 58am blood glucose urean creat na k cl hco3 angap 15pm blood glucose urean creat na k cl hco3 angap 58am blood calcium phos mg 15pm blood calcium phos mg brief hospital course ms was admitted to the acute surgery service for her abdominal pain and ct scan concerning for appendicitis she was taken to the operating room for a diagnostic laparoscopy and open appendectomy she tolerated the procedure well and was extubated in the or she was monitored in the pacu and then transferred to the floor she was kept npo initially her diet was slowly advanced the patient was retaining urine post operatively requiring straight cathx1 early morning pod1 the patient was found to be unresponsive on the floor and was thought to be given too much pain medication she responded to narcan and her pain meds were then held the following day she was started on tramadol for pain control which she tolerated well additionally on pod1 the patient was febrile to her fever curve was trended throughout her hospital stay and she remained afebrile her leukocytosis was also monitored and came down postoperatively from to her vitals were monitored and remained stable prior to discharge she was voiding spontaneously ambulating independently passing flatus tolerating a diet and her pain was controlled medications on admission none discharge medications acetaminophen mg po q4h rx acetaminophen mg tablet s by mouth every hours disp tablet refills ciprofloxacin hcl mg po q12h rx ciprofloxacin hcl mg tablet s by mouth every hours disp tablet refills rx ciprofloxacin hcl mg tablet s by mouth every hours disp tablet refills docusate sodium mg po bid rx docusate sodium colace mg capsule s by mouth every hours disp capsule refills metronidazole mg po q8h rx metronidazole mg tablet s by mouth every hours disp tablet refills tramadol mg po q6h prn pain rx tramadol mg tablet s by mouth every hours disp tablet refills discharge disposition home discharge diagnosis acute appendicitis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms you were admitted to with acute appendicitis you underwent an appendectomy and are now ready to go home please call your doctor or nurse practitioner or return to the emergency department for any of the following you experience new chest pain pressure squeezing or tightness new or worsening cough shortness of breath or wheeze if you are vomiting and cannot keep down fluids or your medications you are getting dehydrated due to continued vomiting diarrhea or other reasons signs of dehydration include dry mouth rapid heartbeat or feeling dizzy or faint when standing you see blood or dark black material when you vomit or have a bowel movement you experience burning when you urinate have blood in your urine or experience a discharge your pain in not improving within hours or is not gone within 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 incision care please call your doctor or nurse practitioner if you have increased pain swelling redness or drainage from the incision site avoid swimming and baths until your follow up appointment you may shower and wash surgical incisions with a mild soap and warm water gently pat the area dry if you have staples they will be removed at your follow up appointment followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies penicillins attending chief complaint shortness of breath and cough major surgical or invasive procedure none history of present illness cc cough history of the presenting illness this is a gentleman with a history of hiv currently on active retroviral therapy hepatitis c who was recently completed treatment who presents with cough patient first noticed a fever and cough days ago he notes that his cough is productive of green yellow sputum as well as some blood tinged sputum intermittently he notes a subjective fever as well as sweating and chills but did not take his temperature at home patient notes that she had some pleuritic right flank pain that has been persistent for the last days and is worse with deep inspiration and with movement it is somewhat tender to palpation the patient denies any diarrhea or constipation or abdominal pain other than the flank pain noted above he has been intermittently taking n p o but notes significant decrease over the last week patient notes that his last cd4 count was just over and that he has recently completed a course of treatment for his hepatitis c with harvoni he has a previous history of iv drug use but has not used iv drugs since in the ed initial vitals were temp hr bp rr spo2 ra exam con ill appearing in no acute distress heent normocephalic atraumatic pupils equal round and reactive to light extraocular muscles intact resp decreased breath sounds in the right middle and lung base cv regular rate and rhythm normal and heart sounds no heart sound no jvd no pedal edema distal upper extremity and lower extremity pulses capillary refill less than seconds abd soft tender to palpation in the right upper quadrant nondistended gu costovertebral angle tenderness worse in the right msk no cyanosis clubbing or edema skin no rash warm and dry no petechiae neuro alert and following commands moving all extremities spontaneously sensation intact to light touch speech fluent psych normal mood mentation labs wbc hgb cr na lactate imaging cxr bibasilar opacities on the right would be compatible with pneumonia in the proper clinical setting and suspected right pleural effusion linear left basilar opacity is likely atelectasis consider pa and lateral views cta chest no evidence of pulmonary embolism or aortic abnormality dense consolidation in a significant portion of the right lower lobe suspicious for pneumonia streaky left basilar opacities likely atelectasis though additional region of infection would be possible trace right pleural effusion ecg ecg sinus rhythm at consults none patient was given po acetaminophen mg iv cefepime ivf lr iv vancomycin iv cefepime g iv vancomycin mg ivf lr ml iv methylprednisolone sodium succ mg iv sulfamethoxazole trimethoprim mg po dolutegravir mg po emtricitabine tenofovir alafen 200mg 25mg descovy tab ros positive per hpi remaining point ros reviewed and negative past medical history narcotic abuse hiv infection hepatitis c social history family history non contributory physical exam admissoin physical exam vitals hr data last updated temp tm bp hr rr o2 sat o2 delivery 2l nc wt lb kg gen alert cooperative no distress appears stated age diaphoretic hent nc at mmm nares patent no drainage or sinus tenderness teeth and gums normal eyes perrl eom intact conjunctivae clear no scleral icterus right neck no cervical lymphadenopathy no jvd no carotid bruit neck supple symmetrical trachea midline lung poor air movement with ronchi at right base and crackles at left base no accessory muscle use heart rrr normal s1 s2 no m r g back symmetric no curvature rom normal no cva tenderness abd soft non tender non distended nl bowel sounds no rebound or guarding no organomegaly gu not examined extrm extremities warm no edema no cyanosis positive pulses bilaterally skin skin color and temperature appropriate no rashes or lesions neur cn ii xii intact grossly moving all extremities strength sensation and reflexes equal and intact throughout psyc mood and affect appropriate he did not do discharge physical exam hr data last updated temp tm bp hr rr o2 sat o2 delivery ra heent normocephalic atraumatic pupils equal round and reactive to light extraocular muscles intact resp decreased breath sounds in the right middle and lung base pain to palpation of r flank and cva cv regular rate and rhythm normal and heart sounds no heart sound no jvd no pedal edema distal upper extremity and lower extremity pulses abd soft ntnd msk no cyanosis clubbing or edema skin no rash warm and dry no petechiae neuro a and o x pertinent results admission labs 23pm urine hours random 23pm urine uhold hold 23pm urine color yellow appear hazy sp 23pm urine blood tr nitrite neg protein glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg 23pm urine rbc wbc bacteria few yeast none epi 49pm po2 pco2 ph total co2 base xs 49pm lactate 49pm o2 sat 43pm glucose urea n creat sodium potassium chloride total co2 anion gap 43pm estgfr using this 43pm alt sgpt ast sgot ld ldh alk phos tot bili 43pm lipase 43pm albumin 43pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 43pm neuts bands lymphs monos eos basos absneut abslymp absmono abseos absbaso 43pm rbcm within nor 43pm plt smr normal plt count 43pm ptt discharge labs 50am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 50am blood glucose urean creat na k cl hco3 angap imaging cta chest impression no evidence of pulmonary embolism or aortic abnormality dense consolidation in a significant portion of the right lower lobe suspicious for pneumonia streaky left basilar opacities likely atelectasis though additional region of infection would be possible trace right pleural effusion other important labs 45am blood wbc lymph abs cd3 abs cd3 cd4 abs cd4 cd8 abs cd8 cd4 cd8 microbiology pm sputum source expectorated gram stain final pmns and epithelial cells 100x field no microorganisms seen quality of specimen cannot be assessed respiratory culture preliminary sparse growth commensal respiratory flora am urine source final report legionella urinary antigen final presumptive positive for legionella serogroup antigen reference range negative performed by immunochromogenic assay clinical correlation and additional testing suggested including culture and detection of serum antibody pm mrsa screen source nasal swab final report mrsa screen final no mrsa isolated brief hospital course patient summary mr is a man with a history of hiv on avrt hepatitis c status post treatment who presented with cough x7 days on admission he endorsed having a productive cough with blood tinged sputum for days fevers at home shortness of breath he denied any chest pain or palpitations he endorsed right flank pain which started around the time of his cough and was made worse with coughing on arrival his temperature was and he was breathing times per minute he was started on nasal cannula oxygen ct chest showed right lower lobe pneumonia with some streaking in left lower lobe he was initially treated with vancomycin cefepime and bactrim also started on prednisone given concern for pcp on the floor legionella urine antigen was positive he was started on azithromycin x7 days and other antibiotics were stopped on he reported more right sided pain secondary to cough and he was concerned about worsening cough since sputum had not resulted he was started on ceftriaxone for strep pneumo coverage he will transition to cefpodoxime on discharge for total day course his cd4 count was found to be he was started on double strength bactrim tab for pcp while on antibiotics his symptoms improved he had diminished o2 requirements and transition to room air and on day of discharge had an ambulatory o2 sat of transitional issues he had elevated transaminases this admission thought to be secondary to legionella please repeat ast and alt in week week of he had a transaminitis this admission thought to be secondary to legionella however given history of hepatitis c hep c viral load was sent and still pending on discharge please follow up viral load cd4 this admission patient adamantly expressed compliance with hiv medications will need follow up with primary care provider regarding adherence with hiv medications vl was pending on discharge please follow up when it results started on pcp prophylaxis with double strength tab already receiving azithromycin for treatment of legionella pneumonia through would likely be indicated for mac prophylaxis going forward as well please continue to follow up as outpatient and determine need for prophylaxis please follow up regarding dose of suboxone per our pharmacy records he last filled prescription on he was started on azithromycin mg twice a day for days end date he was also given a total of days treatment for strep pneumo pna ceftriaxone should start cefpodoxime please confirm he was able to take full antibiotic course as prescribed please ensure pna is resolving sputum culture strep pneumo still pending on discharge please follow up once resulted acute issues legionella pna acute hypoxemic respiratory failure improving patient presented with week of fevers productive cough pleuritic chest pain chest x ray on admission consistent with pna given the patient s most recent cd4 count of he represented a mildly suppressed host and was at higher risk for infections he had an elevated ldh to and bilaterality to his opacities on cxr concerning for pcp ct chest showed right lower lobe pneumonia with some streaking in left lower lobe he was initially treated with vancomycin cefepime and bactrim also started on prednisone given concern for pcp given the fevers to hyponatremia blood tinged sputum and pneumonia urine legionella was obtained legionella urine antigen was positive on with consistent findings of hyponatremia and transaminitis although no gi sx he was started on a course of azithromycin mg twice a day for days end date his other antibiotics were stopped on and his prednisone was stopped beta d glucan was mildly positive but not felt to be reflective of acute fungal infection on given concern for ongoing right sided pain and continued productive cough he was started on ceftriaxone for strep pneumo coverage sputum culture and strep pneumo was still pending on day of discharge plan for transition to cefpodoxime on discharge for total day course end date his symptoms improved with antibiotics and on day of discharge he was satting well on room air had easy work of breathing ambulatory oxygen of sputum culture and strep still pending will need follow up h o hep c elevated transaminitis resolved he had mild elevated transaminases on admission as well as an elevated ldh he was recently treated for hep c and has previously normal lfts medication effect would be a likely culprit however the patient has been on antiretroviral medications for some time without notable lft abnormalities he had a positive legionella ua thus transaminitis likely explained in part by legionella which can cause transaminitis levels were normal by the time of discharge improved patient has a baseline creatinine of with admission creatinine of likely represented a prerenal etiology given the patient s poor p o intake high fevers and diaphoresis he received l of iv to the emergency department and cr down trended to creatinine on day of discharge was anemia he has a history of anemia with baseline hemoglobin around he presented with a hemoglobin of he had a small amount of hemoptysis in the form of blood tinged sputum during his admission but no other evidence of bleeding b12 folate wnl hyponatremia resolved patient was found to be hyponatremic to on admission this was thought to be secondary to legionella pneumonia his sodium improved during his stay and on day of discharge was chronic issues hiv patient has a history of hiv with a most recent cd4 count of he takes descovy and dolutegravir at home the patient believes he is taking his medications however he is not able to recall the names of them when asked given his pneumonia with hypoxemia repeat cd4 counts and hiv viral loads were obtained and cd4 was found to be viral load was still pending on discharge will need to be followed up once resulted patient started on bactrim for pcp was given azithromycin for legionella pna and azithromycin for mac prophylaxis will need to be addressed in outpatient follow up h o ivdu and other opioid use patient reports last used in however prior notes in state patient was still using various opioids pharmacy checked his most recent suboxone filled at outside hospital and he was continued on this dose of mg twice daily medications on admission the preadmission medication list is accurate and complete dolutegravir mg po daily emtricitabine tenofovir alafen 200mg 25mg descovy tab po daily buprenorphine naloxone film 12mg 3mg film sl bid discharge medications azithromycin mg po daily duration days rx azithromycin mg tablet s by mouth once a day disp tablet refills cefpodoxime proxetil mg po bid rx cefpodoxime mg tablet s by mouth twice a day disp tablet refills sulfameth trimethoprim ds tab po buprenorphine naloxone film 12mg 3mg film sl bid dolutegravir mg po daily emtricitabine tenofovir alafen 200mg 25mg descovy tab po daily discharge disposition home discharge diagnosis primary diagnosis legionella pneumonia secondary diagnosis hyponatremia transaminitis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr it was a pleasure taking care of you at the why was i in the hospital you were admitted because you had a lung infection called pneumonia what happened in the hospital you had a chest x ray and chest ct scan that showed an infection in the bottom part of your right lung you are given antibiotics to treat your infection you were also given oxygen to help with your breathing you were given your medications for hiv what should i do when i go home be sure to take all your medications and attend all of your appointments listed below thank you for allowing us to be involved in your care we wish you all the best your healthcare team followup instructions

name unit no admission date discharge date date of birth sex m service neurology allergies lisinopril attending chief complaint transient vision loss and dizziness major surgical or invasive procedure none history of present illness neurology stroke admission consult note no code stroke stroke scale score t pa administered yes time given x no reason t pa was not given or considered nihss thrombectomy performed yes x no reason not performed or considered no lvo nihss performed within hours of presentation at time date nihss total 1a level of consciousness 1b loc question 1c loc commands best gaze visual fields facial palsy 5a motor arm left 5b motor arm right 6a motor leg left 6b motor leg right limb ataxia sensory language dysarthria extinction and neglect reason for consultation transient vision loss and dizziness hpi is a year old male with history of hypertension and hyperlipidemia who presents with minutes of left upper outer quadrant vision loss and vertigo he reports he has been in his usual state of health recently he got up this morning and went on a mile leisurely bike ride he does bike in such a way that he has to hyperextend his neck he then came out and ate some cheese sandwiches and then went about his day he was working on fixing a door and was lifting and straining but felt fine with this activity then he went and sat on the cough and was talking with his wife at all of the sudden he noticed that in his upper outer left field of vision he could not make things out describes seeing light but everything was very blurry he closed one eye at a time and the symptoms were still present with one eye closed he also noticed that he felt like the room was spinning he got up and walked into the kitchen and had to hold onto the kitchen counter he googled his symptoms and looked up things to check for stroke his wife checked his face speech weakness and sensation which were all normal he specifically says he checked for drift of his arms and legs and there was none after about minutes the vision changes and dizziness resolved he called his pcp who recommended he go to an eye doctor he went to mass eye and ear and had a normal dilated eye exam he does report that there was a test in which the ophthalmologist held up a large red box and he had this transient vision change with that in which the very center not left or right of the box was fading from red to black but then these symptoms stopped he has not been sick recently there are no new medications he does report occasional palpitations there is no headache or neck pain ros on neurological review of systems the patient denies headache confusion difficulties producing or comprehending speech diplopia dysarthria dysphagia lightheadedness vertigo tinnitus or hearing difficulty denies focal weakness numbness parasthesiae no bowel or bladder incontinence or retention on general review of systems the patient denies recent fever chills night sweats or recent weight changes denies cough shortness of breath chest pain or tightness palpitations denies nausea vomiting diarrhea constipation or abdominal pain denies dysuria or recent change in bowel or bladder habits denies arthralgias myalgias or rash past medical history hypertension hyperlipidemia gerd social history full time stopped smoking years ago had pack year history no drugs no etoh lives with wife modified rankin scale x no symptoms no significant disability able to carry out all usual activities despite some symptoms slight disability able to look after own affairs without assistance but unable to carry out all previous activities moderate disability requires some help but able to walk unassisted moderately severe disability unable to attend to own bodily needs without assistance and unable to walk unassisted severe disability requires constant nursing care and attention bedridden incontinent dead family history pgf had strokes in father had strokes and mi in his brother had mi at physical exam admission physical exam physical examination vitals t bp hr rr sao2 on ra general awake cooperative heent nc at no scleral icterus noted 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 mental status alert oriented x or able to relate history without difficulty attentive able to name backward without difficulty language is fluent with intact repetition and comprehension normal prosody there were no paraphasic errors able to name both high and low frequency objects able to read without difficulty no dysarthria able to follow both midline and appendicular commands there was no evidence of apraxia or neglect cranial ii iii iv vi mm nr post dilation eomi without nystagmus 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 and tone throughout no pronator drift no adventitious movements such as tremor or asterixis noted delt bic tri ecr fex io ip quad ham ta gas l r sensory no deficits to light touch pinprick or proprioception throughout no extinction to dss romberg absent reflexes bic tri pat ach l r plantar response was flexor bilaterally coordination bilateral intention tremor normal finger tap bilaterally no dysmetria on fnf or hks bilaterally gait good initiation narrow based normal stride and arm swing able to walk in tandem without difficulty discharge physical exam general awake cooperative heent nc at no scleral icterus noted 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 mental status alert able to relate history without difficulty attentive language is fluent with intact repetition and comprehension normal prosody there were no paraphasic errors able to follow both midline and appendicular commands there was no evidence of apraxia or neglect cranial ii iii iv vi eomi without nystagmus vff to confrontation v facial sensation intact to light touch vii no facial droop facial musculature symmetric viii hearing intact to finger rub bilaterally ix x palate elevates symmetrically xi strength in trapezii bilaterally xii tongue protrudes in midline with good excursions motor normal bulk and tone throughout no pronator drift no adventitious movements such as tremor or asterixis noted delt bic tri ecr fex io ip quad ham ta gas l r sensory no deficits to light touch pinprick or proprioception throughout no extinction to dss romberg absent pertinent results 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 alkphos totbili 15pm blood lipase 15pm blood ctropnt 30am blood cholest 15pm blood albumin calcium phos mg 15pm blood hba1c eag 30am blood triglyc hdl chol hd ldlcalc 15pm blood asa neg ethanol neg acetmnp neg tricycl neg 00pm urine blood neg nitrite neg protein neg glucose neg ketone neg bilirub neg urobiln neg ph leuks neg 00pm urine bnzodzp neg barbitr neg opiates neg cocaine neg amphetm neg oxycodn neg mthdone neg transthoracic echo no evidence for right to left intracardiac shunt at rest or with maneuvers the left atrial volume index is normal there is no evidence for an atrial septal defect by 2d color doppler the estimated right atrial pressure is mmhg there is normal left ventricular wall thickness with a normal cavity size there is normal regional and global left ventricular systolic function overall left ventricular systolic function is normal quantitative biplane left ventricular ejection fraction is normal there is no resting left ventricular outflow tract gradient no ventricular septal defect is seen normal right ventricular cavity size with normal free wall motion the aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender the aortic arch diameter is normal with a normal descending aorta diameter there is no evidence for an aortic arch coarctation 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 physiologic tricuspid regurgitation the estimated pulmonary artery systolic pressure is normal there is no pericardial effusion impression normal lv and rv size and systolic function no significant valvular disease lenis no evidence of deep venous thrombosis in the right or left lower extremity veins mr head without contrast no evidence of acute infarction hemorrhage or intracranial mass no evidence of acute infarction hemorrhage or intracranial mass patent intracranial and cervical vasculature without evidence of dissection stenosis vessel occlusion or aneurysm formation greater than mm paranasal sinus disease cxr no acute cardiopulmonary findings brief hospital course brief summary year old male with history of hypertension and hyperlipidemia who presented with minutes of left upper outer quadrant vision loss and vertigo exam on presentation was normal s p a long bike ride likely dehydrated and lifting heavy objects history was concerning for a posterior circulation tia paradoxical embolism he was admitted to stroke team ct cta head and neck and brain mri did not show any acute infarct echo obtained and was reassuring ef bubble study included and did not show a pfo on preliminary review final results pending obtained and no dvt identified stroke labs showed reassuring cbc hba1c of cholesterol triglycerides hdl ldl etiology was presumed to be cardioembolic patient was started on aspirin mg daily and discharged home with outpatient pcp follow up with plan for neurology referral at neurologist exam at discharge was unremarkable without any localizing signs transitional issues follow up final read of tte to confirm no pfo we have started patient on aspirin mg daily baby aspirin we have placed a heart monitor ziopatch the results of this will be communicated to your pcp dr please follow up with pcp who will refer you to an atrius neurologist 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 x no if ldl reason not given statin medication allergy x other reasons documented by physician advanced practice nurse physician physician apn pa or pharmacist ldl at mechanism likely embolic on discussion with pt it was decided that he will first try dietary modification to lower ldl from to less than 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 in written form x yes no assessment for rehabilitation or rehab services considered yes x no if no why not patient at baseline functional status discharged on statin therapy x yes no if ldl reason not given statin medication allergy x other reasons documented by physician advanced practice nurse physician physician apn pa or pharmacist ldl at mechanism likely embolic on discussion with pt it was decided that he will first try dietary modification to lower ldl from to less than 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 cta head and neck no evidence of acute infarction hemorrhage or intracranial mass patent intracranial and cervical vasculature without evidence of dissection stenosis vessel occlusion or aneurysm formation greater than mm paranasal sinus disease mr head there is no evidence of hemorrhage edema masses mass effect midline shift or infarction the ventricles and sulci are normal in caliber and configuration major vascular flow voids are preserved there is mild mucosal thickening along the ethmoid air cells the remainder of the paranasal sinuses appear clear there is trace opacification of the bilateral inferior mastoid air cells the orbits appear unremarkable impression no evidence of acute infarction hemorrhage or intracranial mass echo the left atrial volume index is normal there is no evidence for an atrial septal defect by 2d color doppler the estimated right atrial pressure is mmhg there is normal left ventricular wall thickness with a normal cavity size there is normal regional and global left ventricular systolic function overall left ventricular systolic function is normal quantitative biplane left ventricular ejection fraction is normal there is no resting left ventricular outflow tract gradient no ventricular septal defect is seen normal right ventricular cavity size with normal free wall motion the aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender the aortic arch diameter is normal with a normal descending aorta diameter there is no evidence for an aortic arch coarctation 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 physiologic tricuspid regurgitation the estimated pulmonary artery systolic pressure is normal there is no pericardial effusion impression normal lv and rv size and systolic function no significant valvular disease medications on admission the preadmission medication list is accurate and complete omeprazole mg po daily omeprazole mg po daily losartan potassium mg po daily atorvastatin mg po qpm discharge medications aspirin mg po daily omeprazole mg po daily patient take mg omeprazole alternating with mg every other day atorvastatin mg po qpm losartan potassium mg po daily omeprazole mg po daily patient take mg omeprazole alternating with mg every other day discharge disposition home discharge diagnosis transient ischemic attack discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr you were hospitalized due to symptoms of minutes of left upper outer quadrant vision loss and vertigo resulting from a transient ischemic attack tia a condition where a blood vessel providing oxygen and nutrients to the brain is blocked transiently by a clot the brain is the part of your body that controls and directs all the other parts of your body so damage to the brain from being deprived of its blood supply can result in a variety of symptoms we obtained brain imaging and heart echo which were both reassuring tia can have many different causes so we assessed you for medical conditions that might raise your risk of having tia stroke in order to prevent future strokes we plan to modify those risk factors your risk factors are high blood pressure high cholesterol we are changing your medications as follows we have started you on aspirin mg daily baby aspirin we have placed a heart monitor ziopatch the results of this will be communicated to your pcp and dr please follow up with your pcp who will refer you to an atrius neurologist an appointment with your pcp has been set for at 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 no known allergies adverse drug reactions attending chief complaint right arm weakness and unsteadiness with walking major surgical or invasive procedure none history of present illness is a year old woman with past medical history significant for stroke thought to be hypercoaguable state from ocps and smoking right pericallosal aneurysm s p clipping in hypertension hyperlipidemia who presents with left sided weakness and gait unsteadiness worsening since she reports that sometime on she noticed that her left leg which is always weak seemed weaker than normal as well as her left arm she has noticed that her right leg seemed a little bit weak which was new for her and she knows that she was having trouble writing over the next few days she has had more trouble with her right hand and she has been dropping things she has also had multiple falls yesterday she fell at home and her sister had to help her out because she could not get up on her own she says that she thinks the weakness might feel a little bit better when she is walking around but she feels off balance so she has not been able to walk much she has a hard time describing this feeling of off balance she does not report any room spinning or lightheadedness she just feels like she might fall she has not had any illnesses recently and she has not had any medication changes on neurologic review of systems the patient denies headache lightheadedness or confusion denies difficulty with producing or comprehending speech denies loss of vision blurred vision diplopia vertigo tinnitus hearing difficulty dysarthria or dysphagia denies 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 hyperlipidemia gout cva minimal left hemiparesis history of alcohol dependence fracture femur in social history family history her mother had a stroke hypertension and myocardial infarction family history her mother had a stroke hypertension and myocardial infarction physical exam admission physical exam physical examination vitals t hr bp rr sao2 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 irregular rhymthm s1s2 no m r g noted abdomen soft nt nd normoactive bowel sounds no masses or organomegaly noted extremities no edema skin no rashes or lesions noted neurologic 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 patient was able to name both high and low frequency objects able to read without difficulty speech was not dysarthric able to follow both midline and appendicular commands 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 visual acuity bilaterally with correction v facial sensation intact to light touch vii slight left facial droop which activates symmetrically left orbital fissure slightly wider compared to the right with strong eye closure 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 tone throughout no pronator drift bilaterally no adventitious movements such as tremor noted no asterixis noted delt bic tri wre ffl fe io ip quad ham ta l r sensory no deficits to light touch pinprick cold sensation vibratory sense proprioception throughout no extinction to dss dtrs bi tri pat ach l r plantar response was flexor on right mute on left coordination dysmetria present on finger nose finger left greater than right slight dysmetria present on heel to shin bilaterally patient had dysmetria when reaching for her phone and trying to unlock it when i asked her about it she seemed like she had not noticed it before but seemed to think it was new gait upon sitting up in bed patient with very prominent truncal ataxia but able to sit up straight on standing patient with sway upon taking one step she lost balance and fell onto examiner she said this is how her standing and walking has been at home for the past few days and that she has been using an assistive device to help her but it has not been enough that she has been falling unable to test romberg discharge physical exam objective hr data last updated temp tm bp hr rr o2 sat o2 delivery ra physical exam general comfortable and in no distress head no irritation exudate from eyes nose throat neck supple with no pain to flexion or extension cardio regular rate and rhythm warm no peripheral edema lungs unlabored breathing abdomen soft non tender non distended skin no rashes or lesions neurologic exam mental status alert and oriented x3 attentive speech is fluent without dysarthria able to carry out extensive conversations with good comprehension of hospital course and plan cn ii iii iv vi pupils constrict to 2mm on right and on left visual fields full r ptosis may be chronic v facial sensation intact to light touch bilaterally l side feels of r side chronically vii slight lower l facial droop chronic viii hearing intact to finger rub bilaterally ix x palate elevates symmetrically xi strength in r l trapezii and scm xii tongue protrudes midline motor normal bulk and tone no extraneous movements delt tri bic wre fe ff ip ham ta gas l r pronator drift downwards on l sensory deferred coordination significant dysmetria with to ftn l worse than r reflexes deferred gait very unsteady falling backwards and towards the left left leg drags pertinent results 30am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30am blood glucose urean creat baseline na k cl hco3 angap mri brain few small foci of slow diffusion involving the left corona radiata and left frontal lobe old right frontal parietal infarction where there is associated volume loss a few small old right cerebellar infarcts moderate white matter chronic small vessel ischemic disease status post right frontal craniotomy and clipping of a right pericallosal artery aneurysm echo impression mild moderate mitral regurgitation mild pulmonary artery systolic hypertension normal biventricular cavity sizes with preserved regional and global biventricular systolic function no definite structural cardiac source of embolism identified brief hospital course patient is a year old female with past medical history most remarkable for remote right sided parietal and cerebellar strokes with residual left sided weakness right pericallosal aneurysm status post clipping in hypertension and hyperlipidemia whom presented with right sided weakness found to have left corona radiata infarction etiology of patient s stroke uncertain but suspect paroxysmal atrial fibrillation given large vessel occlusion and now history of bilateral strokes in different vascular territories no atrial fibrillation on telemetry but have arranged for patient to be monitored with outpatient holter scheduled patient has been taking aspirin mg daily for stroke risk reduction but this admission we have switched her to clopidogrel mg daily patient s ldl found to be and we have increased her rosuvastatin to mg daily from mg daily with hopes to get her to goal of less than patient by the time of discharge had full motor strength on the right and her exam remained remarkable for chronic left sided weakness patient was having difficulty with ambulating and was at high risk of falling therefore she was discharged to acute rehabilitation to work on improved and safe ambulation patient was told to follow up with her primary care physician to obtain neurology referral patient should be neurologist in months from discharge transitional issues left corona radiate motor cortex stroke please ensure that patient makes holter placement appointment please ensure patient has scheduled appointment with pcp days post discharge from acute rehabilitation to follow up on this hospitalization and to obtain referral to see neurologist months post discharge leukopenia and thrombocytopenia patient needs to have levels followed up with pcp if chronically low might need hematology work up to rule out hematologic disorder patient also with mild chronic kidney disease and mildly elevated alkaline phosphatase would recommend starting with outpatient spep upep to rule out multiple myeloma hyperlipidemia patient s ldl this admission increased rosuvastatin to mg daily to work towards goal of less than will need to follow up with pcp hypertension there were no changes in her hypertension medications this admission would follow up with pcp to ensure blood pressure adequately managed medications on admission the preadmission medication list is accurate and complete lamotrigine mg po daily metoprolol succinate xl mg po daily lisinopril mg po daily olanzapine mg po daily amlodipine mg po daily rosuvastatin calcium mg po qpm aspirin mg po daily discharge medications clopidogrel mg po daily rosuvastatin calcium mg po qpm amlodipine mg po daily lamotrigine mg po daily lisinopril mg po daily metoprolol succinate xl mg po daily olanzapine mg po daily discharge disposition extended care facility discharge diagnosis left corona radiata stroke discharge condition mental status clear and coherent level of consciousness alert and interactive activity status out of bed with assistance to chair or wheelchair discharge instructions you presented to the hospital with right sided weakness and walking unsteadiness and were found to have had a stroke on the left side of your brain thankfully it looks like you are recovering well from this stroke and we have transferred you to acute rehabilitation to maximize your recovery potential we want to help prevent you from having another stroke and have therefore changed some of your current medications we have started you on clopidogrel mg daily and you will discontinue taking aspirin mg daily we have increased your rosuvastatin to mg daily from mg daily to help tighten control of your blood lipid levels ultimately we are uncertain why you had a stroke but we suspect that you have an abnormal rhythm in your heart that is increasing your risks of having strokes therefore will have scheduled for you to come to pick up a monitor to wear to possibly detect this abnormal rhythm please have your primary care physician send referral for you to follow up with a neurologist in three months so that your stroke management can be reviewed thank you for allowing us to care for you stroke team followup instructions

name unit no admission date discharge date date of birth sex f service orthopaedics allergies demerol codeine vicodin compazine macrobid keflex erythromycin base ciprofloxacin sulfa sulfonamide antibiotics penicillins attending chief complaint r leg pain major surgical or invasive procedure r knee spanning ex fix orif r tibial plateau fracture history of present illness year old female with history of htn and cva presenting with a right tibial plateau fracture s p fall off back of pickup truck no hs loc cth negative no pain in other extremities on exam this is a closed injury and the patient is neurovascularly intact this injury will require surgical fixation past medical history pmh psh htn cva heart murmur ectopic pregnancy hysterectomy social history family history non contributory physical exam exam vitals af bp other vss and within normal limits general well appearing breathing comfortably msk lle dressings c d i after dressing change yesterday fires silt in all distributions well perfused pertinent results 05am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt brief hospital course the patient presented to the emergency department and was evaluated by the orthopedic surgery team the patient was found to have a right bicondylar tibial plateau fracture and was admitted to the orthopedic surgery service the patient was taken to the operating room on for application of an external fixator and again on for removal of the fixator and orif of the bicondylar tibial plateau both of 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 incisions were clean dry intact and the patient was voiding moving bowels spontaneously the patient is touch down weight bearing in the right lower extremity and will be discharged on lovenox for dvt prophylaxis the patient will follow up with dr routine a thorough discussion was had with the patient regarding the diagnosis and expected post discharge course including reasons to call the office or return to the hospital and all questions were answered the patient was also given written instructions concerning precautionary instructions and the appropriate follow up care the patient expressed readiness for discharge medications on admission the preadmission medication list is accurate and complete valsartan mg po daily hydrochlorothiazide mg po daily discharge medications acetaminophen mg po times daily bisacodyl mg po pr daily prn constipation diovan hct valsartan hydrochlorothiazide mg oral daily docusate sodium mg po bid enoxaparin sodium mg sc qhs duration days start today first dose next routine administration time rx enoxaparin mg ml units subcutaneous daily disp syringe refills gabapentin mg po tid tramadol mg po q6h prn pain rx tramadol mg one half tablet s by mouth q6h prn disp tablet refills hydrochlorothiazide mg po daily valsartan mg po daily discharge disposition home with service facility discharge diagnosis right bicondylar tibial plateau fracture discharge condition avss nad a ox3 rle incision well approximated dressing clean and dry fires fhl ta gcs silt n distributions dp pulse wwp distally 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 touch down weight bearing right lower extremity in unlocked brace medications please take all medications as prescribed by your physicians at discharge continue all home medications unless specifically instructed to stop by your surgeon do not drink alcohol drive a motor vehicle or operate machinery while taking narcotic pain relievers narcotic pain relievers can cause constipation so you should drink eight 8oz glasses of water daily and take a stool softener colace to prevent this side effect anticoagulation please take lovenox daily for 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 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 followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies amoxicillin attending chief complaint chest pain major surgical or invasive procedure none history of present illness with h o cardiomyopathy lvef lung cancer s p right upper lobectomy hypertension and hyperlipidemia presented with chest pain patient reports acute onset of chest pain that woke him up from sleep the morning of presentation at about 3a he described the pain as sharp and worse with inspiration it had been constant throughout the course of the day and notably not worse with exertion pain was mainly across the his chest but he also has the sensation that it was traveling down my esophagus and across the top of my back there was no radiation down the arm or to the jaw he reported some limitation in his ability to take a deep breath due to pain but no shortness of breath per se he denied palpitations or diaphoresis patient has never had pain like this before there was no significant improvement in pain by leaning forward he denied any recent uri he did recently travel to a resort in the he denied fevers chills abdominal pain nausea vomiting diarrhea or urinary symptoms in the ed initial vitals hr bp rr sao2 on ra ekg showed new inferior t waver inversions labs studies notable for hgb hct wbc plt na k bun cr troponin t negative x2 nt pro bnp d dimer cxr showed that the heart size and mediastinum were stable with unchanged vascular enlargement in the hila but no evidence of acute exacerbation of congestive heart failure cta showed no evidence of pulmonary embolism or acute aortic abnormality no acute etiology identified for pleuritic chest pain no focal consolidation concerning for underlying infection there was enlargement of the pulmonary arterial system consistent with pulmonary arterial hypertension there was an unchanged soft tissue mass in the prevascular mediastinum which has been slowly growing since and appears stable since probably an encapsulated thymoma thickening the mediastinal esophagus was unchanged compared and may be sequela of chronic esophageal inflammation patient was given aluminum magnesium hydrox simethicone ml po donnatal ml po lidocaine viscous ml po famotidine mg iv nitroglycerin infusion starting at mcg kg min after arrival to the cardiology ward the patient reported persistent pleuritic chest pain he said the nitroglycerin gtt might be helping marginally he had been resting comfortably in bed prior to being woken up to give the above history past medical history cad risk factors hypertension dyslipidemia cardiac history dilated cardiomyopathy attributed to pvc burden cabg none percutaneous coronary interventions none pacing icd none other past medical history lung cancer s p lobectomy no chemo xrt nephrolithiasis colonic polyps high grade prostatic intraepithelial neoplasia neuropathy social history family history mother with rheumatic heart disease father with diabetes and required open heart surgery physical exam on admission general pleasant elderly white man in nad vs t bp hr rr sao2 on ra heent ncat mucous membranes moist cv rrr no murmurs rubs or gallops pulm ctab gi soft non tender not distended bs extremities warm and well perfused no clubbing cyanosis or edema pulses radial pulses bilaterally neuro alert moving all extremities with purpose face symmetric at discharge general pleasant elderly man in nad vs hr data last updated temp tm bp hr rr o2 sat o2 delivery ra heent ncat mucous membranes moist cv rrr no murmurs rubs or gallops pulm ctab gi soft non tender not distended bs extremities warm and well perfused no clubbing cyanosis or edema pulses radial pulses bilaterally neuro alert moving all extremities with purpose face symmetric pertinent results 56am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 56am blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 56am blood glucose urean creat na k cl hco3 angap 56am blood crp 30am blood vitb12 folate hapto 56am blood probnp 56am blood ctropnt 05pm blood ctropnt 30am blood ctropnt discharge labs 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 ecgs ecg stable anterior j point elevation new inferior t wave inversions with subsequent widening of the qrs duration into a not quite lbbb ivcd cxr heart size and mediastinum are stable in appearance vascular enlargement in the hila is unchanged with no evidence of acute exacerbation of congestive heart failure on the radiograph postsurgical changes in the right lung are stable there is no pleural effusion there is no pneumothorax cta chest heart and vasculature pulmonary vasculature is well opacified to the subsegmental level without filling defect to indicate a pulmonary embolus there is enlargement of the main right main and left main pulmonary arteries measuring up to and cm respectively these findings are likely suggestive of pulmonary arterial hypertension the thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma the heart pericardium and great vessels are within normal limits no pericardial effusion is seen axilla hila and mediastinum mediastinal esophagus appears thickened throughout its course series image similar compared to prior and suggestive of underlying chronic esophageal inflammation again seen in the mediastinum along the superior aspect of the left ventricle adjacent to the main pulmonary artery there is a lobulated homogeneous x cm soft tissue density which previously measured x cm this mass is been slowly growing since and likely represent an encapsulated thymoma it appears to now abut the myocardium over a couple of cm there is no axillary lymphadenopathy there are prominent subcarinal and right hilar lymph nodes which are nonspecific pleural spaces no pleural effusion or pneumothorax lungs airways changes seen after right upper lobectomy there is bibasilar atelectasis right greater than left without focal consolidation concerning for infection incidentally noted is an azygos lobe mm nodule in the right upper lobe series image is unchanged compared to and now stable for months no additional concerning nodules are identified base of neck visualized portions of the base of the neck show no abnormality abdomen included portion of the upper abdomen is unremarkable bones no suspicious osseous abnormality is seen there is no acute fracture impression no evidence of pulmonary embolism or acute aortic abnormality no acute etiology identified for pleuritic chest pain no focal consolidation concerning for underlying infection enlargement of the pulmonary arterial system consistent with pulmonary arterial hypertension unchanged soft tissue mass in the prevascular mediastinum which has been slowly growing since and appears stable since this is probably an encapsulated thymoma thickening the mediastinal esophagus is unchanged compared and may be sequela of chronic esophageal inflammation egd could be pursued on a nonurgent basis if clinically indicated echocardiogram the left atrial volume index is normal there is normal left ventricular wall thickness with a normal cavity size there is mild moderate global left ventricular hypokinesis the visually estimated left ventricular ejection fraction is there is no resting left ventricular outflow tract gradient normal right ventricular cavity size with normal free wall motion the aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender the aortic arch diameter is normal the aortic valve leaflets are mildly thickened 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 mild mitral regurgitation the tricuspid valve leaflets appear structurally normal there is physiologic tricuspid regurgitation there is moderate pulmonary artery systolic hypertension there is no pericardial effusion compared with the prior tte images not available for review of the estimated pa systolic pressure is now increased brief hospital course with h o cardiomyopathy lvef lung cancer s p right upper lobectomy hypertension and hyperlipidemia presented with chest pain he had negative troponin t x3 he was also found to have esophagitis with chest pain improved with initiation of ppi and aluminum magnesium hydrox simethicone acute issues chest pain esophagitis patient was admitted with acute onset chest pain described as burning around esophagus radiating across shoulders and to lesser degree across chest not classic for acs ecg initially with some inferoapical t wave inversion non specific though no other changes suggestive of acute ischemia but troponin t and ck mb negative x3 initial treatment with nitroglycerin gtt without obvious improvement in pain cta also negative after patient noted to recently have been on relatively long plane flight and with elevated d dimer patient reported no symptoms during recent trip to but a lot of stress during the flight home most likely etiologies of chest pain felt to be esophagitis given thickened mediastinal esophagus on cta vs pericarditis with elevated crp significant relief of chest pain with empiric treatment of esophagitis with gi cocktail and pantoprazole therefore treatment of pericarditis not initiated at time of discharge chest pain was almost completely gone and patient only reported faint sensation of burning around esophagus non conducted p waves bradycardia telemetry pause with non conducted p waves sec longer qrs free interval than expected if single non conducted pac with apparent av block after a likely p wave vs artifact failure of ventricular escape and or av block patient does not recall what he was doing at the time pause and tracing reviewed with several electrophysiologists as sinus node dysfunction isolated and asymptomatic no further intervention was felt warranted at present patient mentioned that dr mentioned possibility of icd presumably primary prevention patient discharged with outpatient ep f u with dr we decreased home metoprolol succinate dose given occasional bradycardia hr dilated cardiomyopathy lvef in on cmr in presumed to be secondary to vea burden per recent cardiology note initially started on metoprolol and lisinopril with reduction in pvc burden to and subsequently was initiated on amiodarone therapy in with most recent holter on showing reduction vpc burden to with multiple morphologies continued home amiodarone decreased dose of metoprolol as above chronic issues ckd stage with cr on admission baseline downtrended to this admission hypertension continued home hydralazine once daily dosing confirmed by patient hctz metoprolol hyperlipidemia continued home statin lung ca s p right upper lobectomy no chemo xrt surveillance imaging as outpatient primary prevention against cad continued home aspirin statin metoprolol transitional issues follow up resolution of chest pain with gi cocktail and pantoprazole further workup of esophagitis would recommend endoscopy with dr follow up of non conducted p waves in clinic with dr icd for primary prevention he was noted to have left leg calf pain which is suspicious for claudication and pad would recommend an outpatient abi and vascular medicine follow up to assess this consider ett mibi or r mibi develops claudication after walking miles slowly but useful to assess functional capacity if symptoms not improve with aggressive gi regimen follow up of likely thymoma noted on cta new meds gi cocktail qid pantoprazole mg daily stopped held meds none changed meds metoprolol succinate xl mg mg daily follow up appointments pcp appointment with dr appointment with dr follow up with dr post discharge follow up labs needed none incidental findings thymoma left leg claudication discharge weight 8kg discharge creatinine code full presumed contact wife medications on admission the preadmission medication list is accurate and complete amiodarone mg po daily gabapentin mg po bid hydralazine mg po daily hydrochlorothiazide mg po daily metoprolol succinate xl mg po daily simvastatin mg po qpm aspirin mg po daily vitamin d unit po daily cyanocobalamin mcg po daily multivitamin plus multivitamin minerals lutein oral daily selenium mcg oral daily florastor saccharomyces boulardii mg oral daily discharge medications aluminum magnesium hydrox simethicone ml po qid rx alum mag hydroxide simeth mg mg mg ml ml by mouth four times a day disp milliliter refills pantoprazole mg po q24h rx pantoprazole mg tablet s by mouth once a day disp tablet refills metoprolol succinate xl mg po daily rx metoprolol succinate mg tablet s by mouth once a day disp tablet refills amiodarone mg po daily aspirin mg po daily cyanocobalamin mcg po daily florastor saccharomyces boulardii mg oral daily gabapentin mg po bid hydralazine mg po daily hydrochlorothiazide mg po daily multivitamin plus multivitamin minerals lutein oral daily selenium mcg oral daily simvastatin mg po qpm vitamin d unit po daily discharge disposition home discharge diagnosis chest pain esophagitis dilated cardiomyopathy chronic left ventricular systolic heart failure non conducted p waves consistent with asymptomatic sinus node dysfunction bradycardia acute kidney injury on chronic kidney disease stage normocytic anemia left calf claudication consistent with peripheral arterial disease hypertension hyperlipidemia mediastinal mass discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr it was a pleasure caring for you at why was i in the hospital you were admitted because of chest pain what happened in the hospital you were admitted to the hospital because you had chest pain lab tests of your blood found that your cardiac enzymes were normal not elevated and you had electrocardiograms ekgs that did not show a heart attack you had an imaging test called a ct angiogram of your chest there was no sign of a blood clot in your lung pulmonary embolus and no signs of aortic dissection however the ct angiogram showed a mass in the mediastinum that is likely a thymoma that should be followed up as an outpatient the cta showed thickening of your esophagus that could be a sign of esophagitis inflammation of the esophagus which was likely causing your chest pain you were treated with a gi cocktail medication and a proton pump inhibitor that helps to reduce acid in the stomach and your pain improved you were noted to have slow heart rates and a pause on cardiac telemetry monitoring you should see your cardiologist dr in clinic for follow up what should i do when i go home continue to take the gi cocktail and proton pump inhibitor follow up with your gastroenterology doctor we recommend getting an endoscopy to look at your esophagus you should get a test called an ankle brachial index abi as an outpatient to work up your left calf tightness thank you for allowing us to be involved in your care we wish you all the best your healthcare team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies percocet amoxicillin pot clavulanate attending chief complaint chest pain major surgical or invasive procedure none history of present illness female with history of gerd hypertension hyperlipidemia who presented to the ed for evaluation of intermittent chest pressure with left arm tingling radiating to her left face over the past few weeks worsening over the past few days episodes last a few minutes at a time and were occurring more frequently up to episodes per day worse with any exertion past medical history shingles ibs htn anxiety hypercholesterolemia back injury varicose veins recent work up for vaginal bleeding found to have a vaginal wall tear after tvus social history family history her mother had a myocardial infarction at age deceased from this and father myocardial infarction at age survived to brother had coronary artery bypass graft at age all members were smokers physical exam on admission physical examination general neuro nad x a o x non focal x cardiac rrr x irregular nl s1 s2 murmur systolic diastolic rusb jvd cm lungs cta x no resp distress x abd nbs soft nd nt extremities edema doppler palpable x at discharge physical exam general neuro nad x a o x non focal x cardiac rrr x irregular nl s1 s2 murmur systolic diastolic rusb jvd cm lungs cta x no resp distress x abd nbs x soft x nd x nt x extremities edema doppler palpable x pertinent results cardiac perfusion study date of technique isotope data mci tc 99m sestamibi rest mci tc 99m sestamibi stress summary of data from the exercise lab exercise protocol modified duration minutes reason exercise terminated fatigue resting heart rate resting blood pressure peak heart rate peak blood pressure percent maximum predicted hr symptoms during exercise none ecg findings mm upsloping scooping st segment depression noted inferolaterally most st segment changes resolved quickly post exercise however the mm scoping st segment depression remained throughout recovery st segments returned to baseline by minutes post exercise resting perfusion images were obtained with tc 99m sestamibi tracer was injected approximately minutes prior to obtaining the resting images at peak exercise approximately three times the resting dose of tc 99m sestamibi was administered iv stress images were obtained approximately minutes following tracer injection imaging protocol gated spect this study was interpreted using the segment myocardial perfusion model findings left ventricular cavity size is normal resting and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium gated images reveal normal wall motion the calculated left ventricular ejection fraction is with an end diastolic volume of cc impression no evidence of reversible myocardial ischemia normal left ventricular cavity size and systolic function stress study date of interpretation yo woman with hl htn and bmi of was referred to evaluate an atypical chest discomfort the patient completed minutes of a modified protocol representing an average exercise tolerance for her age mets the exercise test was stopped due to fatigue no chest back neck or arm discomforts were reported at peak exercise mm upsloping scooping st segment depression was noted inferolaterally although these st segment changes appeared to resolve quickly post exercise mm scooping st segment depression remained throughout recovery the st segments were back to baseline by minutes post exercise the rhythm was sinus with rare isolated apbs resting systolic and diastolic hypertension with an appropriate hemodynamic response noted with exercise impression average exercise tolerance nonspecific st segment changes in the absence of anginal symptoms nuclear report sent separately portable tte complete done at am conclusions the left atrium is mildly dilated no atrial septal defect is seen by 2d or color doppler the estimated right atrial pressure is mmhg left ventricular wall thickness cavity size and global systolic function are normal lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded right ventricular chamber size and free wall motion are normal the ascending aorta is mildly dilated the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened trivial mitral regurgitation is seen the estimated pulmonary artery systolic pressure is normal there is no pericardial effusion there is an anterior space which most likely represents a prominent fat pad impression suboptimal image quality preserved global biventricular systolic function no clinically significant valvular regurgitation or stenosis normal pulmonary pressure chest pa lat study date of impression no acute cardiopulmonary process 50am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 50am blood plt 50am blood glucose urean creat na k cl hco3 angap 00pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 00pm blood plt 00pm blood ptt 00pm blood glucose urean creat na k cl hco3 angap 00pm blood alt ast alkphos totbili 00pm blood lipase 25pm blood ctropnt 00pm blood ctropnt 00pm blood probnp 00pm blood albumin calcium phos mg 03pm blood k ssessment plan yo woman presented in ed with midsternal chest pain pressure with intermittent complaint over past month of sob jaw tingling and head pressure negative troponin x2 ecg sinus rhythm no st changes admitted for stress test chest pain has not recurred cardiac enzymes neg x reassuring echo ekg stress testing gerd continue home dose of ranitidine 150mg bid hypertension continue amlodipine mg daily hyperlipidemia continue pravastatin mg daily chronic back pain well managed with home prns continue nambumetone hydrocodone acetaminophen prn back pain anxiety continue home regimen of alprazolam mg prn code status full dispo home transitional issues patient confirms she will arrange pcp appointment in weeks and prefers to make own new patient cardiologist appointment recommending cardiologist follow up in weeks patient confirms understanding medications on admission the preadmission medication list is accurate and complete alprazolam mg po tid prn anxiety amlodipine mg po daily ranitidine mg po bid pravastatin mg po qam hydrocodone acetaminophen 5mg 325mg tab po q6h prn pain moderate nabumetone mg po q12h prn back pain amitriptyline mg po daily prn leg clamps discharge medications alprazolam mg po tid prn anxiety amitriptyline mg po daily prn leg clamps amlodipine mg po daily hydrocodone acetaminophen 5mg 325mg tab po q6h prn pain moderate nabumetone mg po q12h prn back pain pravastatin mg po qam ranitidine mg po bid discharge disposition home discharge diagnosis chest pain discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted to for work up of chest pain blood tests and ekgs indicated that you did not have a heart attack a stress test did not show abnormal heart function these test results are reassuring that there is not a dangerous cardiac cause for your chest pain we did not make any changes to your usual medication regimen please continue all of your pre hospitalization medications exactly as prescribed please follow up with your primary care physician within the next weeks please follow up with a cardiologist within the next weeks if you have any urgent questions that are related to your recovery from your medical issues or are experiencing any symptoms that are concerning to you and you think you may need to return to the hospital please call the heartline at to speak to a cardiologist or cardiac nurse practitioner followup instructions