Datasets:

MiniML

/

mimiciv_icd10

like 0

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 ve been depressed major surgical or invasive procedure none history of present illness history was noted from dr consult note from and subsequent psychiatry cl notes in omr confirmed with patient and updated as relevant briefly patient is a year old man with history of etoh use disorder depression and past paranoid ideation medical history of htn hld who presents to the with progressively worsening depression c b hopelessness with suicidal ideation in the context of self discontinuing his psychiatric medications approximately weeks ago as well as multiple psychosocial stressors per dr consultation note on interview patient states that he has been experiencing severe depression over the past two weeks with frequent thoughts of si he reports prominent hopelessness low energy sleep interruptions poor motivation and decreased interest he denies plan or intent in regards to suicidality but reflects that he wants to get help before i get that bad again patient reports that his depression became notably worse in the context of his brother becoming acutely ill approximately months ago during this time he was regularly caring for his brother who was on the waiting list for an organ transplant however he passed away months ago before he was able to receive one since his brother s passing he reports that his nieces and nephews have been taking advantage of him patient reports that approximately one month ago he checked myself into for similar symptoms of depression along with suicidal ideation and plan to kill himself by strapping weights to my body and drowning myself he found the hospitalization helpful but did not follow up with aftercare and stopped taking his psychiatric medications once he ran out in order to snap myself out of the depression he recently grinded his thumb into a block of wood he reflects that he had hoped the physical pain would improve his emotional pain but now is experiencing both types of pain he also reports a history of paranoid ideation reflecting that it tends to get worse when his depression is bad he reports that recently he has been feeling that people are going to harm me on admission interview patient confirms much of the above he reports being depressed for the past months with the depression worsening in the past couple of months after the death of his brother he discusses how he left his own apartment to move in with his brother and care for him his brother s two sons did not want him living there and ultimately forced the patient to leave shortly after the patient moved out his brother passed away the patient believes it is because he was not being cared for properly he states that his nephews may have issues with drugs he states that he was hospitalized at about month ago after he left he went to while he was there he was told that he would be unable to leave to go to his psychiatry appointment he left there after staying for about days he has since been living with either his sister or friends however he suspects that his friend is involved with drugs he reports erratic sleep decreased appetite with a lb weight loss in the past few weeks decreased energy and decreased concentration he reports that about a month ago he thought about jumping off of a bridge with a weight attached to him however he has since learned that suicide is a moral sin and he no longer would want to commit suicide for that reason denies current si states that he feels safe on the unit he reports recent self harm behaviors as above of rubbing his thumb into wood in order to inflict pain on himself to snap out of his depression psychiatric ros depression as per hpi psychosis reports that he has had paranoia for most of his adult life stating that he used to feel like people wanted to kill him continues to report some paranoia but states that it is much improved mania denies symptoms including decreased need for sleep increase in goal directed behavior and increased energy anxiety denies past psychiatric history per dr confirmed with patient and updated as relevant hospitalizations recently at for si plan month ago reports additional hospitalization months ago current treaters and treatment psychiatrist is dr that he sees him approximately once month medication and ect trials reports seroquel has been helpful in the past for paranoid thoughts most recently reports taking wellbutrin and adderall which were both helpful but he ran out self injury no suicide attempts recently injured right thumb as per hpi harm to others none reported access to weapons denies past medical history per dr confirmed with patient and updated as relevant htn hld back pain social history family history per dr confirmed with patient and updated as relevant reports history of bpad in his mother etoh abuse in siblings both sides of his family physical exam vs t bp hr r o2 sat on ra general middle aged male in nad well nourished well developed appears stated age heent normocephalic atraumatic eomi back no significant deformity lungs cta no crackles wheezes or rhonchi cv rrr no murmurs rubs gallops abdomen bs soft nontender nondistended no palpable masses or organomegaly extremities no clubbing cyanosis or edema skin erythema and bruising at right thumb neurological cranial nerves eom full facial symmetry on eye closure and smile symmetric hearing grossly normal phonation normal shoulder shrug intact tongue midline motor normal bulk and tone bilaterally no abnormal movements no tremor strength full power throughout gait steady normal stance and posture no truncal ataxia cognition wakefulness alertness awake and alert attention intact to interview states myob with error orientation oriented to person time place situation executive function go no go luria trails fas not tested memory intact to recent and past history fund of knowledge consistent with education calculations correctly states quarters in abstraction not assessed visuospatial not assessed speech normal rate volume and tone language native speaker no paraphasic errors appropriate to conversation mental status appearance no apparent distress appears stated age mildly disheveled dressed in hospital gown behavior calm cooperative engaged appropriate eye contact no psychomotor agitation or retardation mood and affect depressed restricted thought process linear coherent goal oriented no loa thought content denies si hi ah vh no evidence of delusions reports mild chronic paranoia judgment and insight fair fair pertinent results 35pm blood glucose urean creat na k cl hco3 angap 18am blood hba1c eag 18am blood triglyc hdl chol hd ldlcalc 18am blood tsh 35pm blood asa neg ethanol neg acetmnp neg tricycl neg 27pm urine bnzodzp neg barbitr neg opiates neg cocaine neg amphetm neg oxycodn neg mthdone neg brief hospital course legal safety on admission the patient signed a conditional voluntary agreement section and remained on that level throughout their admission he was also placed on minute checks status on admission and remained on that level of observation throughout while being unit restricted psychiatric patient was admitted to inpatient psychiatry due to depression with passive suicidal ideation in the context of self discontinuing his psychiatric medications approximately weeks prior and psychosocial stressors on admission interview patient reported worsening depression in the context of the death of his brother months prior with associated poor sleep decreased appetite with a lb weight loss in the past few weeks decreased energy and decreased concentration denied si on admission stating that he realized that suicide is a moral sin and he no longer would not commit suicide for that reason he was continued on his home gabapentin discussed decreasing with the patient he was taking mg bid continued adderall at mg bid in order to not precipitate withdrawal during hospitalization patient has also noted to be irritable tangential and hyper verbal concerning for an underlying bipolar disorder and current mixed state he was started on risperdal which was titrated to mg qhs he was given hydroxyzine prn and ramelteon prn for sleep the patient often reported to the team improved mood and sleep however would also report irritability and agitation he was noted to be attending groups and social in the milieu obtained psychological testing where patient endorsed depression and distress there were also questions raising possibility of cluster b personality traits although patient initially denied si he intermittently reported vague si in the context of discharge planning however ultimately at discharge patient was secured a bed at a css he reported an improved mood and reported that he felt safe to discharge he reported that he would be able to reach out for help if he felt poorly and would seek hospitalization if he felt unsafe substance use disorders alcohol use disorder patient reported a history of heavy alcohol use in the past reported being sober for the last month patient reported motivation to continue to abstain from alcohol use throughout hospitalization opioid use disorder patient was continued on suboxone daily as patient reported that he had been taking less than suboxone bid that was prescribed in he reported that he was trying to get off suboxone patient was encouraged to follow up with his outpatient provider for further adjustments in suboxone medical right thumb cellulitis patient reported that prior to admission in order to snap myself out of the depression he grinded his thumb into a block of wood he completed a course of cephalexin mg po q6h for cellulitis the cellulitis improved and patient reported no pain or discomfort at discharge psychosocial groups milieu the patient was encouraged to participate in the various groups and milieu therapy opportunities offered by the unit the patient often attended these groups that focused on teaching patients various coping skills he was noted to be pleasant and an active participant when not in groups he was social with peers in the milieu there were no behavioral concerns requiring restraint or seclusion homelessness patient reported that he did not have stable housing after leaving his brothers house once his brother passed away patient often discussed housing issues with the team although stated that housing was not an issue as he could always stay with friends social work assisted the patient with housing options and he reported to the team that he completed an application for the in the patient was discharged to a css placement collateral contacts family involvement the team called and left a message for patient s outpatient psychiatrist dr did not hear back the patient declined to have the social worker contact his sister guardianship n a informed consent the team discussed the indications for intended benefits of and possible side effects and risks of starting risperidone and risks and benefits of possible alternatives including not taking the medication with this patient we discussed the patient s right to decide whether to take this medication as well as the importance of the patient s actively participating in the treatment and discussing any questions about medications with the treatment team and i answered the patient s questions the patient appeared able to understand and consented to begin the medication risk assessment on presentation the patient was evaluated and felt to be at an increased risk of harm to himself due to depression and si the patient is chronically at risk for self harm due to factors such as chronic mental illness history of substance abuse history of abuse recent discharge from an inpatient psychiatric unit male gender caucasian race age and martial status during hospitalization patient reported motivation continue to abstain from alcohol he reported improved mood he is being discharged with protective factors that make him appropriate for outpatient care at this time including help seeking nature good relationship with his outpatient psychiatrist good knowledge of resources available to him no si strong religious beliefs and future orientation with plans to follow up on housing applications and with his outpatient psychiatrist our prognosis of this patient is guarded medications on admission the preadmission medication list is accurate and complete aspirin mg po daily atenolol mg po daily gabapentin mg po tid simvastatin mg po qpm ranitidine mg po bid buprenorphine naloxone 8mg 2mg tab sl daily amphetamine dextroamphetamine mg po bid discharge medications hydroxyzine mg po qhs prn anxiety insomnia rx hydroxyzine hcl mg tablet by mouth at bedtime disp tablet refills melatonin mg oral qhs prn rx melatonin mg tablet s by mouth at bedtime disp tablet refills risperidone mg po qhs mood disorder rx risperidone mg tablet s by mouth at bedtime disp tablet refills amphetamine dextroamphetamine mg po bid rx dextroamphetamine amphetamine adderall mg tablet s by mouth twice a day disp tablet refills atenolol mg po daily rx atenolol mg tablet s by mouth daily disp tablet refills gabapentin mg po bid rx gabapentin mg tablet s by mouth twice a day disp tablet refills aspirin mg po daily rx aspirin mg tablet s by mouth daily disp tablet refills buprenorphine naloxone 8mg 2mg tab sl daily ranitidine mg po bid rx ranitidine hcl mg tablet s by mouth twice a day disp tablet refills simvastatin mg po qpm rx simvastatin mg tablet s by mouth at bedtime disp tablet refills discharge disposition extended care discharge diagnosis major depressive disorder r o bad i mixed discharge condition vitals t bp hr rr o2 appearance middle aged male no apparent distress wearing casual street clothes good hygiene behavior calm cooperative mood and affect good euthymic thought process linear goal directed thought content denies si hi does not report avh judgment and insight fair fair discharge instructions you were hospitalized at for depression please follow up with all outpatient appointments as listed take this discharge paperwork to your appointments unless a limited duration is specified in the prescription please continue all medications as directed until your prescriber tells you to stop or change please avoid abusing alcohol and any drugs whether prescription drugs or illegal drugs as this can further worsen your medical and psychiatric illnesses please contact your outpatient psychiatrist or other providers if you have any concerns please call or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers it was a pleasure to have worked with you and we wish you the best of health followup instructions

name unit no admission date discharge date date of birth sex m service surgery allergies penicillins attending complaint fap major surgical or invasive procedure laparoscopic total proctocolectomy with ileal low rectal pouch anastomosis with proximal diverting ileostomy history of present illness referred to dr surgical treatment of fap he was referred for genetic testing as an outpatient prior to surgery surgical arrangements were made by dr surgery past medical history pmh familial adenomatous polyposis rectal cancer psh none on file social history employeed at married supportive wife physical general doing well tolerating a regular diet pain controlled ambulating vss neruo a ox3 cardio pulm no chest pain or shortness of breath abd obese soft surgical incisions intact without signs of infection ileostomy pink with liquid stool output no lower extremity edema pertinent results admission 10am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 10am blood glucose urean creat na k cl hco3 angap 10am blood calcium phos mg discharge 35am 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 ct marked distention of the stomach and entire small bowel proximal to the diverting ileostomy with transition point appearing at the ileostomy itself with dilated proximal loop and decompressed exiting loop of ileum consistent with small bowel obstruction no evidence of hypoenhancing bowel or free intraperitoneal air hepatic steatosis brief hospital course mr is a with a t2n0 rectal cancer in the setting of numerous polyps now tested positive for mutyh mutation consistent with map who come in for a scheduled total laparascopic protocolectomy with ileoanal pouch and diverting ileostomy he tolerated the procedure very well after a brief and uneventful stay in the pacu he was admitted to the floor for further management his post op course was initially complicated by post op ileus which resolved after nasogastric tube placement and then later high ileostomy output which subsequently resolved he was discharged home post op day in good condition with services for ostomy care at discharge he was tolerating regular diet appropriate ileostomy output ambulating without assistance medications on admission atorvastatin mg tablet citalopram mg tablet dicyclomine mg tablet fluticasone mcg actuation nasal spray hydrochlorothiazide mg tablet lisinopril lorazepam mg mirtazapine mg omeprazole mg oxybutynin chloride er rizatriptan mg prn tamsulosin days before syrgery topiramate cetirizine mg discharge medications acetaminophen mg po q8h prn pain mild loperamide mg po qid titrate according to ostomy volume and consistency rx loperamide anti diarrhea mg mg by mouth four times a day disp tablet refills oxycodone immediate release mg po q4h prn pain moderate rx oxycodone mg tablet s by mouth disp tablet refills psyllium wafer waf po tid atorvastatin mg po qpm cetirizine mg po daily citalopram mg po daily fluticasone propionate nasal spry nu bid fluticasone salmeterol diskus inh ih bid hydrochlorothiazide mg po daily lorazepam mg po qpm omeprazole mg po daily oxybutynin mg po bid topiramate topamax mg po daily discharge disposition home with service facility discharge diagnosis preoperative diagnosis familial adenomatous polyposis with myh variation with a known rectal cancer postoperative diagnosis familial adenomatous polyposis with myh variation with a known rectal cancer discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent gen nad heent ncat eomi cv rrr pulm normal excursion no respiratory distress abd soft nt nd ostomy with brown output and some gas lap sites cdi ext no edema neuro grossly intact discharge instructions mr were admitted to the hospital after a proctectomy with ileal pouch anal anastomosis and diverting loop ileostomy for surgical management of your ulcerative colitis have recovered from this procedure well and are now ready to return home samples from your colon were taken and this tissue has been sent to the pathology department for analysis will receive these pathology results at your follow up appointment if there is an urgent need for the surgeon to contact regarding these results they will contact before this time have tolerated a regular diet passing gas and your pain is controlled with pain medications by mouth may return home to finish your recovery if have any of the following symptoms please call the office for advice fever greater than increasing abdominal distension increasing abdominal pain nausea vomiting inability to tolerate food or liquids prolonged loose stool extended constipation inability to urinate incisions have small laparascopic incision sites with steri strips in place those will eventually fall off on their own this is healing well however it is important that monitor these areas for signs and symptoms of infection including increasing redness of the incision lines white green yellow malodorous drainage increased pain at the incision increased warmth of the skin at the incision or swelling of the area may shower pat the incisions dry with a towel do not rub the small incisions may be left open to the air if closed with steri strips little white adhesive strips these will fall off over time please do not remove them please no baths or swimming until cleared by the surgical team it is expected that may still have pain after surgery and this pain will gradually improved over the course of your stay here will especially have pain when changing positions and with movement should continue to take extra strength tylenol for pain every hours around the clock and may also take advil ibuprofen 600mg every hours for days please do not take more than 3000mg of tylenol in hours or any other medications that contain tylenol such as cold medication do not drink alcohol while or tylenol please take advil with food if these medications are not controlling your pain to a point where can ambulate and preform minor tasks should take a dose of the narcotic pain medication oxycodone please take this only if needed for pain do not take with any other sedating medications or alcohol do not drive a car if taking narcotic pain medications may feel weak or washed out for up to weeks after surgery no heavy lifting greater than a gallon of milk for weeks may climb stairs may go outside and walk but avoid traveling long distances until speak with your surgical team at your first follow up visit your surgical team will clear for heavier exercise and activity as the observe your progress at your follow up appointment should only drive a car on your own if are off narcotic pain medications and feel as if your reaction time is back to normal so can react appropriately while driving have a new ileostomy the most common complication from a new ileostomy placement is dehydration the output from the stoma is stool from the small intestine and the water content is very high the stool is no longer passing through the large intestine which is where the water from the stool is reabsorbed into the body and the stool becomes formed must measure your ileostomy output for the next few weeks the output from the stoma should not be more than 1500cc or less than 500cc if find that your output has become too much or too little please call the office for advice the office nurse or nurse practitioner can recommend medications to increase or slow the ileostomy output keep yourself well hydrated if notice your ileostomy output increasing take in more electrolyte drink such as gatorade please monitor yourself for signs and symptoms of dehydration including dizziness especially upon standing weakness dry mouth headache or fatigue if notice these symptoms please call the office or return to the emergency room for evaluation if these symptoms are severe may eat a regular diet with your new ileostomy however it is a good idea to avoid fatty or spicy foods and follow diet suggestions made to by the ostomy nurses monitor the appearance of the ostomy and stoma and care for it as instructed by the wound ostomy nurses stoma intestine that protrudes outside of your abdomen should be beefy red or pink it may ooze small amounts of blood at times when touched and this should subside with time the skin around the ostomy site should be kept clean and intact monitor the skin around the stoma for bulging or signs of infection listed above please care for the ostomy as have been instructed by the wound ostomy nurses will be able to make an appointment with the ostomy nurse in the clinic days after surgery will have a visiting nurse at home for the next few weeks helping to monitor your ostomy until are comfortable caring for it on your own thank for allowing us to participate in your care our hope is that will have a quick return to your life and usual activities good luck followup instructions

name unit no admission date discharge date date of birth sex m service surgery allergies penicillins attending complaint loop ileostomy major surgical or invasive procedure reversal of ileostomy history of present illness w recently diagnosed sigmoid colon cancer presents to clinic to discuss surgical management pt underwent colonoscopy on for brbpr which she reports she has had intermittently for months to years also reports she has not had any brbpr since the colonoscopy this was pt s colonoscopy a cm mass was identified cm from the anal verge pathology returned as invasive adenocarcinoma a ct torso was performed and did not find any evidence of distant disease past medical history pmh familial adenomatous polyposis rectal cancer psh none on file social history family history no ibd or colorectal cancer father cad pvd anxiety mother died of cervical cancer at age has brothers sisters one of her sisters has grave s disease physical exam discharge physical exam vs avss gen well appearing nad heent no lymphadenopathy moist mucous membranes lungs respirations are unlabored on room air heart normal rate and regular rhythm abd non distended appropriately tender no rebound or guarding incisions the ostomy site is left open to heal by secondary intent with minimal serosanguinous drainage extremities warm and well perfused with no edema pertinent results 42am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 25am blood glucose urean creat na k cl hco angap brief hospital course mr presented to holding at on for an ileostomy takedown and reversal he she tolerated the procedure well without complications please see operative note for further details after a brief and uneventful stay in the pacu the patient was transferred to the floor for further post operative management neuro pain was well controlled on oral pain medication with intravenous morphine for breakthrough cv vital signs were routinely monitored during the patient s length of stay and demonstrated no abnormalities pulm the patient was encouraged to ambulate sit and get out of bed use the incentive spirometer and had oxygen saturation levels monitored as indicated gi the patient was initially kept npo after the procedure the patient was later advanced to and tolerated a regular diet at time of discharge the patient had increased number of bowel movements post operatively and loperamide and psyllium were added to his medication regimin he was discharged with instructions on how to titrate the medication himself if he needed to at home on discharge he was having one small bowel movement every couple hours gu patient had a foley catheter that was removed at time of discharge urine output was monitored as indicated at time of discharge the patient was voiding without difficulty id the patient s vital signs were monitored for signs of infection and fever the patient was started on continued on antibiotics as indicated heme the patient had blood levels checked post operatively during the hospital course to monitor for signs of bleeding the patient had vital signs including heart rate and blood pressure monitored throughout the hospital stay on the patient was discharged to home at discharge he she was tolerating a regular diet passing flatus stooling voiding and ambulating independently she will follow up in the clinic in weeks this information was communicated to the patient directly prior to discharge medications on admission pysllium powder loperamide atorvastatin cetirizine citalopram fluticasone omeprazole oxybutynin topiramate discharge medications oxycodone immediate release mg po q4h prn pain moderate reason for prn duplicate override alternating agents for similar severity do not drink alcohol or drive a car while taking this medication rx oxycodone mg tablet s by mouth every four hours disp tablet refills psyllium powder pkt po bid acetaminophen mg po q8h prn pain moderate do not take more than 3000mg of tylenol in hours or drink alcohol while taking atorvastatin mg po qpm cetirizine mg po daily citalopram mg po daily fluticasone propionate nasal spry nu bid loperamide mg po qid rx loperamide mg tablets by mouth four times a day disp tablet refills omeprazole mg po daily oxybutynin mg po bid topiramate topamax mg po daily discharge disposition home discharge diagnosis ileostomy status post total proctocolectomy with ileoanal pouch discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted to the hospital after an ileostomy takedown you have recovered from this procedure well and you are now ready to return home you have tolerated a regular diet passing gas and your pain is controlled with pain medications by mouth you may return home to finish your recovery please monitor your bowel function closely you may or may not have had a bowel movement prior to your discharge which is acceptable however it is important that you have a bowel movement in the next days after anesthesia it is not uncommon for patient s to have some decrease in bowel function but your should not have prolonged constipation some loose stool and passing of small amounts of dark old appearing blood are expected however if you notice that you are passing bright red blood with bowel your please seek medical attention if you are passing loose stool without improvement please call the office or go to the emergency room if the symptoms are severe if you are taking narcotic pain medications there is a risk that you will have some constipation please take an over the counter stool softener such as colace and if the symptoms does not improve call the office it is also not uncommon after an ileostomy takedown to have frequent loose stools until you are taking more regular food however this should improve the muscles of the sphincters have not been used in quite some time and you may experience urgency or small amounts of incontinence however this should improve if you do not show improvement in these symptoms within days please call the office for advice occasionally patients will need to take a medication to slow their bowel movements as their bodies adjust to the new normal without an ileostomy you should consult with our office for advice if you have any of the following symptoms please call the office for advice or go to the emergency room if severe increasing abdominal distension increasing abdominal pain nausea vomiting inability to tolerate food or liquids prolonged loose stool or constipation you have a small wound where the old ileostomy once was this should be covered with a dry sterile gauze dressing the wound no longer requires packing with gauze packing strip please monitor the incision for signs and symptoms of infection including increasing redness at the incision opening of the incision increased pain at the incision line draining of white green yellow foul smelling drainage or if you develop a fever please call the office if you develop these symptoms or go to the emergency room if the symptoms are severe you may shower let the warm water run over the wound line and pat the area dry with a towel do not rub please apply a new gauze dressing after showering no heavy lifting for at least weeks after surgery unless instructed otherwise by your surgical team you may gradually increase your activity as tolerated but clear heavy exercise with your surgical team you will be prescribed a small amount of the pain medication oxycodone please take this medication exactly as prescribed you may take tylenol as recommended for pain please do not take more than 3000mg of tylenol daily do not drink alcohol while taking narcotic pain medication or tylenol please do not drive a car while taking narcotic pain medication thank you for allowing us to participate in your care our hope is that you will have a quick return to your life and usual activities good luck followup instructions

name unit no admission date discharge date date of birth sex m service surgery allergies penicillins attending complaint incisional hernias x major surgical or invasive procedure herniorrhaphy incisional x2 with mesh history of present illness mr underwent reversal of his ileostomy on and was able to be discharged home after approximately days he had a much less eventful postoperative course then after his pouch procedure he was sent home on imodium and fiber supplementation for the expected liquid and frequent bowel movements however he has not been able to make his initial postoperative appointments in cancer clinic because he was concerned about driving all the way to given the frequency and looseness of his stools he has been in frequent communication with my office including discussions with my nurse regarding agents to slow down his bowel movements he has been on imodium and fiber we were considering adding lomotil and recently i started him on cyproheptadine with significant improvement he is down from bowel movements a day to perhaps he is not having any accidents at night in fact he is able to sleep through the night he now reports that his bowel movements are roughly the consistency of pudding his only other complaint is of perianal irritation and redness secondary to his frequent bowel movements past medical history pmh familial adenomatous polyposis rectal cancer psh none on file social history family history no ibd or colorectal cancer father cad pvd anxiety mother died of cervical cancer at age has brothers sisters one of her sisters has grave s disease physical exam gen nad cv rrr pulm nonlabored breathing on room air abd soft nontender nondistended dressings c d i brief hospital course patient underwent incisional hernia repair x2 with mesh ileostomy and umbilical port sites please see operative note for details he tolerated the procedure well post operatively he was voiding spontaneously ambulating pain well controlled tolerating regular diet vitals stable he was safe and stable for discharge to home the same day appropriate instructions and follow up appointments were made medications on admission atorvastatin citalopram mg cyproheptadine fluticasone mirtazapine rizatriptan mg prn topiramate imodium discharge medications acetaminophen mg po q8h oxycodone immediate release mg po q3h prn pain moderate rx oxycodone mg tablet s by mouth every four hours disp tablet refills atorvastatin mg po qpm citalopram mg po daily cyproheptadine mg po q8h fluticasone propionate nasal spry nu bid mirtazapine mg po qhs topiramate topamax mg po daily discharge disposition home discharge diagnosis incisional hernia discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent 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 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 f service orthopaedics allergies sulfa sulfonamide antibiotics macrodantin ampicillin attending chief complaint right ankle fracture major surgical or invasive procedure open reduction internal fixation right ankle fracture history of present illness w r ankle fx s p orif w dr on past medical history anxiety bronchitis esophagus gerd hypothyroid psh dental surgery only denies abdominal procedures social history family history non contributory physical exam alert oriented rle splint clean dry intact moving all toes toes wwp silt distally pertinent results 35pm glucose urea n creat sodium potassium chloride total co2 anion gap 35pm estgfr using this 35pm 25oh vitd 35pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 35pm plt count 35pm ptt brief hospital course mrs was directly admitted from clinic for surgery she underwent orif of right ankle fracture on with dr she tolerated the procedure well all of her home medications were resumed she worked with who determined that discharge to rehab was appropriate she will be taking aspirin for weeks for dvt prophylaxis she received doses of ancef postoperatively her hospital course is otherwise uncomplicated medications on admission the preadmission medication list is accurate and complete quetiapine fumarate mg po qhs clonazepam mg po qhs estradiol mg po twice weekly liothyronine sodium mcg po daily paroxetine mg po daily discharge medications acetaminophen mg po q6h prn pain mild aspirin mg po daily duration weeks docusate sodium mg po bid prn constipation ondansetron mg po q8h prn n v oxycodone immediate release mg po q4h prn pain moderate rx oxycodone mg tablet s by mouth every four hours disp tablet refills liothyronine sodium mcg po daily clonazepam mg po qhs estradiol mg po twice weekly paroxetine mg po daily quetiapine fumarate mg po qhs discharge disposition home with service facility discharge diagnosis right ankle 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 non weight bearing right lower extremity please keep splint clean dry at all times please take aspirin for weeks follow up with dr as scheduled off of narcotics physical therapy physical therapy non weight bearing right lower extremity okay for hip knee range of motion treatments frequency physical therapy non weight bearing right lower extremity okay for hip knee range of motion 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 occipital headache and syncope found to have chiari malformation major surgical or invasive procedure s p suboccipital craniotomy for chiari malformation c1 laminectomy history of present illness m who initially presented to clinic after the patient had been getting a hair cut by his girlfriend when he tilted his head backwards and forward and developed excruciating occipital headache which was briefly associated with nausea he then developed dizziness and passed out he has struck the right orbital area there was loss of consciousness for approximately seconds there was no seizure notified tongue biting or loss of bladder control the patient recovered and the next day was referred to ed ct revealed a chiari malformation and he was recommended to have an mri he presents today for suboccipital craniotomy for chiari malformation and c1 laminectomy past medical history asthma back pain social history family history mother with recent stroke physical exam on discharge tm hr bp rr spo2 ra exam opens eyes x spontaneous to voice to noxious orientation x person x place x time follows commands simple x complex none pupils perrl 3mm bilat eom x full restricted face symmetric x yes no tongue midline x yes no pronator drift yes x no speech fluent x yes no comprehension intact x yes no motor normal bulk and tone bilaterally no abnormal movements tremors strength full power throughout sensation intact to light touch wound suboccipital crani dressing removed incision well approximated and closed with sutures no drainage or erythema pertinent results please see omr for pertinent lab and imaging results brief hospital course chiari malformation patient presents on for elective suboccipital craniotomy for chiari malformation and c1 laminectomy the case was uncomplicated see omr for detailed operative report he was extubated in the or and transferred to pacu for post anesthesia monitoring he remained hemodynamically and neurologically stable and was transferred to the for ongoing neurologic monitoring his a line and foley were removed on pod1 he ambulated with nursing on pod and was independent on pod patient initially who had nausea postoperatively which resulted with antiemetics and scope patch by pod patient s nausea was improved patient was reporting adequate pain control and he was ready to for discharge home patient was discharged home on with prescriptions and plan for follow up in clinic medications on admission albuterol prn discharge medications acetaminophen mg po q6h prn fever or pain cyclobenzaprine mg po tid prn muscle spasms rx cyclobenzaprine mg tablet s by mouth q8hr disp tablet refills docusate sodium mg po bid oxycodone immediate release mg po q4h prn pain rx oxycodone mg tablet s by mouth q6hr disp tablet refills discharge disposition home discharge diagnosis chiari malformation discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions discharge instructions suboccipital craniotomy for decompression chiari malformation and spine surgery without fusion surgery your dressing came off on the second day after surgery your incision is closed with sutures you will need suture removal please keep your incision dry until suture removal do not apply any lotions or creams to the site please avoid swimming for two weeks after suture staple removal call your surgeon if there are any signs of infection like redness fever or drainage activity we recommend that you avoid heavy lifting running climbing or other strenuous exercise until your follow up appointment you make take leisurely walks and slowly increase your activity at your own pace try to do too much all at once no driving while taking any narcotic or sedating medication no contact sports until cleared by your neurosurgeon medications please do not take any blood thinning medication aspirin ibuprofen plavix coumadin until cleared by the neurosurgeon you may use acetaminophen tylenol for minor discomfort if you are not otherwise restricted from taking this medication it is important to increase fluid intake while taking pain medications we also recommend a stool softener like colace pain medications can cause constipation when to call your doctor at for severe pain swelling redness or drainage from the incision site fever greater than degrees fahrenheit new weakness or changes in sensation in your arms or legs severe pain swelling redness or drainage from the incision site fever greater than degrees fahrenheit nausea and or vomiting extreme sleepiness and not being able to stay awake severe headaches not relieved by pain relievers seizures any new problems with your vision or ability to speak weakness or changes in sensation in your face arms or leg call and go to the nearest emergency room if you experience any of the following sudden numbness or weakness in the face arm or leg sudden confusion or trouble speaking or understanding sudden trouble walking dizziness or loss of balance or coordination sudden severe headaches with no known reason followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies codeine escitalopram lisinopril aspirin latex hydrochlorothiazide attending chief complaint hyponatremia major surgical or invasive procedure none history of present illness ms is a year old woman with hypertension hypothyroidism and anxiety presenting with hyponatremia found on outside labs for approximately the past days she has not been feeling herself over this time frame she has had a headache dizziness general weakness and bilateral tinnitus notably in the end of she has a diarrheal illness which her son had at the same time she recovered from this spontaneously she went to an urgent care on and was given hctz 25mg bid for hypertension she took a single dose of this medication on in the evening she then presented to her primary care physician for hypertension and had a chem panel drawn in this setting her sodium resulted as and she was called to come to the ed her last sodium check prior to this was about months prior and was normal at of note she describes an incident about years ago when she was very weak after a diarrheal illness and collapsed she was admitted to the hospital at that time reportedly because of severe hyponatremia ms reports she typically has about cups of tea every morning and then bottles of water later in the day overall she eats a fairly mixed diet she has not had chest pain vomiting diarrhea fevers chills she endorses some anorexia in the ed initial vitals t97 hr bp rr o2 ra exam physical general well appearing heent mmm neck supple lungs ctab normal work of breathing heart rrr normal s1 s2 no murmurs abd soft nontener nondistended skin wwp cap refill sec ext no edema ecchymosis neuro cn ii xii grossly intact strength and sensation to light touch throughout her initial sodium was on presentation she received 1l ns for this and overcorrected to she then received ddavp 2mcg and her sodium dropped to before coming to the floor ros positives as per hpi otherwise negative past medical history osteoporosis anxiety htn hypothyroidism sciatica social history family history no known family history of electrolyte derangement physical exam admission physical examination vs t98 hr bp rr ra gen sitting up in bed and speaking with me somewhat anxious eyes pupils equal and reactive no icterus or injection hennt moist mucous membranes cv s1 s2 regular with no murmurs rubs or s3 s4 resp clear bilaterally no respiratory distress gi soft non tender non distended ext warm extremities no lower extremity edema skin warm dry bruising on l dorsum of hand neuro cn ii xii normal strength in upper and lower extremities psych anxious appearing discharge physical examination vs hr data last updated temp tm bp hr rr o2 sat o2 delivery ra gen ambulating around room hall nad eyes pupils equal and reactive no icterus or injection hennt moist mucous membranes no clad cv s1 s2 regular with no murmurs rubs or s3 s4 resp clear bilaterally no respiratory distress gi soft non tender non distended ext warm extremities no lower extremity edema skin warm dry neuro cn ii xii normal strength in upper and lower extremities psych mildly anxious appearing pertinent results admission laboratory studies 30pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30pm blood urean creat na k cl hco3 angap 59am blood calcium phos mg discharge and pertinent laboratory studies 26am blood na k 12pm blood na 22pm blood na 48pm blood na 28pm blood na k 27pm blood na 12am blood na 36am blood na 29am blood na 08pm blood na 35pm blood na 52pm blood na 07am blood na reports and imaging studies cxr findings the lungs are hyperexpanded there is no focal consolidation pleural effusion or pneumothorax identified the size of the cardiomediastinal silhouette is within normal limits the bony thorax is grossly intact impression no acute cardiopulmonary abnormality microbiology urine culture final mixed bacterial flora colony types consistent with skin and or genital contamination brief hospital course assessment plan w htn hypothyroidism and anxiety p w hyponatremia that is likely multifactorial iso recent hctz use and excessive water intake in relation to solute intake hyponatremia days of constitutional symptoms prompting pcp visit and lab testing revealing hyponatremia to likely multifactorial in the setting of poor solute intake high water intake recent hctz use have been precipitated by diarrheal illness weeks ago she seems prone to this with a similar episode about years ago received a total of doses of ddavp while in the icu sodium improved with 1l day fluid restriction however by day of discharge it had not fully normalized and urine osms had increased to from raising the possibility of an additional underlying process such as siadh discharged home on fluid restriction per renal recommendation with pcp in two days for sodium check hctz added to allergy list discharge na by serum by whole blood plan for repeat labs on with results faxed to pcp and nephrology pcp received warm hand off on patient htn on metop xl tid at home which is an unusual regimen appears that patient feels some sense of reassurance by taking this medication more frequently we therefore changed her metoprolol succ to metop tartrate tid added amlodipine 5mg daily for blood pressure control chronic issues anxiety continued home alprazolam gerd continued maalox ranitidine transitional issues blood sodium consider siadh if not normalized patient was taking metoprolol xl tid at home we changed this to metop tartrate tid hctz added to allergy list would use caution with diuretics in this patient given 2x episodes of hyponatremia blood pressures on amlodipine 5mg initiated on discharge medications on admission the preadmission medication list is accurate and complete levothyroxine sodium mcg po daily metoprolol succinate xl mg po tid alprazolam mg po tid prn anxiety acetaminophen mg po q6h prn pain mild fever ibuprofen mg po q8h prn pain mild discharge medications amlodipine mg po daily rx amlodipine mg tablet s by mouth daily disp tablet refills metoprolol tartrate mg po tid rx metoprolol tartrate mg tablet s by mouth three times a day disp tablet refills acetaminophen mg po q6h prn pain mild fever alprazolam mg po tid prn anxiety levothyroxine sodium mcg po daily outpatient lab work e87 please obtain chem fax results to attention md discharge disposition home discharge diagnosis hyponatremia discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms it was a pleasure taking part in your care here at why was i admitted to the hospital you were admitted because you had a low sodium level in your blood the medical term for this condition is hyponatremia what was done for me while i was in the hospital your blood s sodium level was increased to a near normal level by managing your body s fluid level your blood sodium level did not completely normalize and we made an appointment for you with your pcp to follow up on this issue as an outpatient in the next days what should i do when i leave the hospital limit your fluid intake to no more than liter per day until you see your pcp make sure to attend your scheduled pcp appointment which should be scheduled for days from your discharge from the hospital please make sure to get labs drawn on the results will be faxed to your doctors we started you on amlodipine which is blood pressure medication in place of hctz please take all of your medications as prescribed sincerely your care team followup instructions

name unit no admission date discharge date date of birth sex f service obstetrics gynecology allergies no known allergies adverse drug reactions attending chief complaint large symptomatic fibroid uterus major surgical or invasive procedure abdominal myomectomy lysis of adhesions partial omentectomy and drainage of a left ovarian cyst history of present illness who on underwent a bilateral uterine fibroid embolization again she presents to discuss further the requested operative management she continues to have pelvic pain fullness constipation increased urinary frequency on she had an mr of her pelvis which showed large fibroid uterus extending to the upper abdomen the uterus including fibroids measured x x cm minimally decreased in size prior to examination on when it measured x x cm the endometrium was somewhat distorted by the fibroids the largest intramural fibroid was at the uterine fundus minimally decreased in size and measured x x cm previously measured x x cm this fibroid subserosal less than intramural and did not abut the endometrium an additional large fibroid was subserosal pedunculated fibroid on the right which measured x x cm previously measured x x cm minimally decreased in size two additional large subserosal pedunculated fibroids arise from the anterior lower uterus measuring x x cm previously measured x x cm and last x x cm previously x x cm both of these fibroids were minimally decreased in size from prior examination the ovaries were normal in appearance trace pelvic free fluid was in physiologic limits these findings were discussed with the patient and her questions were answered her pap was negative for intraepithelial lesion or malignancy and she tested negative for the high risk hpv she also had a negative endometrial biopsy her hct was she continues to eat iron rich food and supplement with daily po iron of note she continues to have decreased platelets and is being seen by her hematologist i am waiting for intraoperative and post operative recommendations past medical history ob gyn hx g0 would like to keep future childbearing options open if possible menarche x x hx of heavy menses with no clots no metrorraghia no post coital bleeding absent dyspareunia no dysmenorrhea problems fibroids uterus keratitis overweight pharyngitis surgical history none social history social history family history family history mgm hypertension denies family hx of gyn malignancies dm cad physical exam pre admission physical exam wdwn obese woman in nad bp weight with clothes with shoes height bmi lmp abdomen soft obese nondistended nontender there was a large palpable mass fingerbreadths above the umbilicus from the pubic symphysis to the top of the uterine fundus is cm there was no inguinal lymphadenopathy and again no tenderness on palpation of this mass which was c w a large uterus pelvic deferred secondary to the patient having no complaints discharge physical exam vitals vss gen nad a o x cv rrr resp no acute respiratory distress abd soft appropriately tender no rebound guarding incision c d i ext no ttp pertinent results 19pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 19pm plt count brief hospital course on ms was admitted to the gynecology service after undergoing abdominal myomectomy lysis of adhesions partial omentectomy and drainage of a left ovarian cyst during her procedure fibroids were removed the largest being 20cm notably there were multiple adhesions concerning for previous pid immediately post op her pain was controlled with iv dilaudid toradol please see the operative report for full details on post operative day her urine output was adequate so her foley was removed and she voided spontaneously her post operative course was complicated by persistant tachycardia and development of a post operative ileus she had symptomatic tachycardia to the 120s ekg showed sinus tachycardia her hematocrit was trended her pre op hct of and remained stable at an appropriate decrease to after an intraoperative ebl 500cc her urine output remained adequate tachycardia was not responsive to a fluid bolus a cta was ordered to rule out a thromboembolic event which was significant for no segmental pe and showed only bilateral atelectasis and a fluid filled gastric lumen consistent with an ileus she was started on subcutaneous heparin prophylactically she had a leukocytosis with a max of with no other accompanying symptoms such as fever or chill or other localizing symptoms such as severe abdominal pain dysuria cough sputum production of note the patient has had an elevated heart rates since her uterine artery embolization during which time she was extensively worked up and thought to be secondary to post embolization syndrome on pod she had an episode of 600cc of emesis she was made npo overnight the following day her diet was advanced without incident with no additional episodes of emesis she was transitioned to po oxycodone ibuprofen acetaminophen for pain control 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 cardiology and gynecology follow up scheduled medications on admission medications prescription ibuprofen ibuprofen mg tablet tablet s by mouth q6 hours as needed for pain cramping not taking as prescribed medications otc multivitamin daily multi vitamin daily multi vitamin tablet one tablet s by mouth once daily prescribed by other provider discharge medications acetaminophen mg po q6h prn pain mild no more than 4g in 24hrs rx acetaminophen mg tablet s by mouth every hrs disp tablet refills docusate sodium mg po bid rx docusate sodium mg capsule s by mouth twice a day disp capsule refills ibuprofen mg po q6h prn pain mild take with food no more than 2400mg in 24hrs rx ibuprofen mg tablet s by mouth every hrs disp tablet refills oxycodone immediate release mg po q4h prn pain moderate don t drink alcohol and don t drive on this medication rx oxycodone mg tablet s by mouth every hrs 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 dear ms you were admitted to the gynecology service after your procedure you have recovered well and the team believes you are ready to be discharged home please call dr office with any questions or concerns please follow the instructions below general instructions take your medications as prescribed do not drive while taking narcotics take a stool softener such as colace while taking narcotics to prevent constipation do not combine narcotic and sedative medications or alcohol do not take more than 4000mg acetaminophen apap in 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 you may eat a regular diet you may walk up and down stairs incision care you may shower and allow soapy water to run over incision no scrubbing of incision no tub baths for weeks if you 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 you are unable to keep down fluids food or your medication to reach medical records to get the records from this hospitalization sent to your doctor at home call followup instructions

name unit no admission date discharge date date of birth sex f service surgery allergies shellfish derived attending chief complaint fall major surgical or invasive procedure none history of present illness patient is with pmh of pe dvt on warfarin alzheimer s nonverbal at baseline who presents as a transfer from after evaluation of witnessed fall from her nursing home today history and exam limited as patient has dementia and is nonverbal at baseline per notes year old female with alzheimer s nonverbal presenting after a witnessed fall at her facility she struck her head and was transferred here she is not endorsing any pain or changes from her baseline she has a 2cm laceration on her right forehead and significant swelling and bruising around her right eye she takes warfarin at vitals t100 6r ra patient s pe was significant for tenderness to palpation and pain with movement of the right wrist remainder of the exam was unremarkable labs were notable for inr of ct head wo contrast showed acute sah along the frontal and temporal lobes bilaterally with no midline shift ct cervical spine wo contrast showed no fracture or traumatic malalignment she received k centra splint was applied to right wrist and her laceration over her right eye was treated with dermabond prior to transfer at vitals were ra at the bedside patient endorses pain in right wrist denies ha chest pain or abdominal pain past medical history pmh dvt pe alzheimers dementia volvulus social history family history non contributory physical exam physical general nad vitals ra heent perrla 2cm laceration to right forehead with swelling and ecchymosis around right eye cardio rrr ii vi systolic murmur pulm breathing comfortably on ra abdomen soft nt nd no rebound or guarding neuro aox1 to self believes she is at home responds to name intermittently follows commands moving extremities spontaneously denies sensory deficits extremities warm well perfused trace peripheral edema ace wrap over right wrist skin grade pressure ulcer to left of coccyx physical exam at discharge vs ra heent perrla 2cm laceration r supraorbital healing r infraobrital hematoma healing cardio rrr soft ii systolic murmur pulm clear to auscultation bl abdomen soft nt nd no rebound or guarding neuro aox1 to self not place or time moving extremities spontaneously with slow to respond on right lower extrem extremities warm well perfused trace peripheral edema r arm in cast pertinent results wrist xray impression overlying cast material obscures fine bony detail similar appearance of slightly impacted dorsally angulated distal intra articular fracture of the radius ct head wo con impression slight increase in the volume of subarachnoid hemorrhage particularly in the right sylvian fissure since the prior study otherwise unchanged examination cxr impression no focal consolidation stable small hiatal hernia and mild cardiomegaly pelvis impression no evidence of acute fracture or dislocation with limited evaluation of the sacrum due to overlying bowel gas labs 10am ctropnt 40pm urine color yellow appear clear sp 40pm urine blood tr nitrite neg protein tr glucose neg ketone neg bilirubin neg urobilngn neg ph leuk mod 40pm urine rbc wbc bacteria none yeast none epi 40pm urine hyaline 40pm urine mucous rare 07pm lactate k 00pm glucose urea n creat sodium potassium chloride total co2 anion gap 00pm ctropnt 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 brief hospital course ms was transferred to from after a witnessed fall at her facility with a right radius fracture supraorbital laceration and subarachnoid hemorrhage at the outside hospital she received k centra splint was applied to right wrist and dermabond over her right eye laceration prior to transfer when she presented to she was febrile with urine sample consistent with a urinary tract infection and was treated with ceftriaxone her coumadin was held while in the hospital on hd2 she was noted to have evolution of the subarachnoid hemorrhage per neurosurgery this is the expected sequelae on hd2 she was monitored for cardiac ectopy to further work up her fall none was reported by nursing as visualized by the monitor she was on telemetry and will discharge you with a holter monitor for further cardiac workup she was seen by orthopedics who placed a brace on her right wrist she was seen by neurosurgery who determined no surgery was necessary tertiary trauma survey was complete without new findings she was discharged on hd3 to a rehabilitation facility to continue physical therapy medications on admission the preadmission medication list is accurate and complete warfarin mg po daily levothyroxine sodium mcg po daily furosemide mg po daily donepezil mg po qhs multivitamins tab po daily vitamin d dose is unknown po daily discharge medications acetaminophen mg po tid please do not exceed 4000mg in hours docusate sodium mg po bid senna mg po hs vitamin d unknown po daily donepezil mg po qhs furosemide mg po daily levothyroxine sodium mcg po daily multivitamins tab po daily held warfarin mg po daily this medication was held do not restart warfarin until and after you talk to your pcp about the risks and benefits of this drug discharge disposition extended care facility discharge diagnosis mechanical fall subarachnoid hemorrhage radius fracture r discharge condition mental status confused sometimes level of consciousness alert and interactive activity status out of bed with assistance to chair or wheelchair discharge instructions dear ms you were transferred to from after a witnessed fall at her facility with a radius fracture on the r supraorbital laceration and subarachnoid hemorrhage at the outside hospital you received k centra splint was applied to right wrist and dermabond over your right eye laceration prior to transfer when you got to you were noted to have a urinary tract infection which we treated with antibiotics we placed you on telemetry and will discharge you with a holter monitor for further cardiac workup you were seen by orthopedics who placed a brace on your right wrist you were seen by neurosurgery who determined no surgery was necessary you are doing well and are ready for discharge general surgery 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 new onset 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 holter there was concern that your heart may be the case for your falls you were placed on a holter monitor at the time of discharge your cardiac monitor will be evaluated after days if you have any questions please call the office medications please resume all regular home medications please hold coumadin for total of 7days until at least and you talk to your pcp about the risks and benefits with restarting this medication also please take any new medications as prescribed general care please get plenty of rest continue to ambulate several times per day and drink adequate amounts of fluids avoid lifting with your right arm until you are cleared by physical therapy or your orthopedic surgeon as an outpatient avoid driving or operating heavy machinery while taking pain medications thank you for letting us participate in your care followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies shellfish derived attending chief complaint altered mental status major surgical or invasive procedure none history of present illness ms is a female with the past medical history noted below who was recently admitted at on trauma service from and discharged to a facility her brief hospital summary from dr paperwork is copied below for reference on the day of admission which was the same day as discharge from prior hospitalization pt was found to be altered in her room at the facility and had removed her splint from her arm her daughter hcp was called who felt that she was significantly off her baseline and very agitated seemingly delirious and she was sent back to for further evaluation upon arrival to er she was seen by trauma surgery and her arm was casted her labs and nchct were normal given her lack of surgical or trauma indication but her persistent ams she was admitted to internal medicine for further workup and evaluation of her ams she was admitted to 11r at approximately 0615am on at which time she was minimally responsive and sleeping all vs were normal no immediate medical interventions were made at the time of admission i called her daughter following my initial examination of the patient and corroborated the history further discussion of plan below brief hospital course ms was transferred to from after a witnessed fall at her facility with a right radius fracture supraorbital laceration and subarachnoid hemorrhage at the outside hospital she received k centra splint was applied to right wrist and dermabond over her right eye laceration prior to transfer when she presented to she was febrile with urine sample consistent with a urinary tract infection and was treated with ceftriaxone her coumadin was held while in the hospital on hd2 she was noted to have evolution of the subarachnoid hemorrhage per neurosurgery this is the expected sequelae on hd2 she was monitored for cardiac ectopy to further work up her fall none was reported by nursing as visualized by the monitor she was on telemetry and will discharge you with a holter monitor for further cardiac workup she was seen by orthopedics who placed a brace on her right wrist she was seen by neurosurgery who determined no surgery was necessary tertiary trauma survey was complete without new findings she was discharged on hd3 to a rehabilitation facility to continue physical therapy past medical history pmh dvt pe alzheimers dementia volvulus social history family history fh non contributory physical exam discharge exam vitals afebrile and vital signs stable see eflowsheet general minimally verbal but engaged and making eye contact eyes anicteric pupils equally round periorbital echhymoses ent ears and nose without visible erythema masses r eyebrow laceration abrasion healing 3cm r facial echhymosis 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 patient wearing diaper no rash appreciated msk neck supple moves all extremities did not test strength sensation due to patient s ability to participate rue casted from fingers to elbow in sling skin no rashes or ulcerations noted multiple echhymoses on lue and rue neuro unable to complete neurological exam due to patient s ability to cooperate w exam psych quiet tracking with her eyes minimally responsive pertinent results 15am blood tsh basic coagulation ptt plt inr ptt plt ct brief hospital course hospital course and transitional issues ams pt was found to be at baseline w in 12hrs after arrival this was likely subsequently pt had no further e o ams she was agitated but not obtunded there was no suspicion that she had a seizure all labs normal except tsh as below non con head ct normal hypothyroid pt s tsh was checked and found to be dose was down titrated from 150mcg to 125mcg daughter aware of this change outpatient provider should check tsh in to titrate dose accordingly dispo pt discharged to a long term care facility w follow up appt s scheduled anticipated length of stay of less than days medications on admission the preadmission medication list is accurate and complete acetaminophen mg po tid docusate sodium mg po bid senna mg po hs levothyroxine sodium mcg po daily multivitamins tab po daily donepezil mg po qhs furosemide mg po daily warfarin mg po daily discharge medications levothyroxine sodium mcg po daily acetaminophen mg po tid docusate sodium mg po bid donepezil mg po qhs furosemide mg po daily multivitamins tab po daily senna mg po hs warfarin mg po daily discharge disposition extended care facility discharge diagnosis altered mental status discharge condition minimally verbal but engages with eye contact and occasional verbal replies discharge instructions you were hospitalized for confusion you improved during the course of your hospitalization and now are stable to go to a long term care facility followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies no known allergies adverse drug reactions attending chief complaint ruq abdominal flank pain r pleuritic chest pain major surgical or invasive procedure none history of present illness with gerd hiatal hernia h o thyroid ca s p thyroidectomy years ago who presents with ruq lower r chest pain since patient reports pain started suddenly and was initially concerned that it was muscle pull or reflux she took pepcid without benefit unable to sleep given pain took tabs ibuprofen without relief pain was worse with inspiration worse when lying on affected side denies chest pain denies sob denies lightheadedness denies edema not affected by eating pt does have a h o gallstones no f c n v d in the ed initial vitals were ra exam notable for tachy to otherwise vss gen well appearing cv rrr no m r g resp unable to take deep breath ctab chest wall no ttp abd non distended soft non tender neg sign ext no swelling no calf tenderness labs notable for ddimer imaging was notable for cta chest segmental and subsegmental pulmonary emboli within the right lower lobe associated with pulmonary infarction in the peripheral anterior aspect of the right lower lobe no ct evidence for right heart strain small right pleural effusion cxr wedge shaped opacity within the periphery of the right lower lobe concerning for pulmonary infarction and further assessment with chest cta is recommended to evaluate for pulmonary embolism no pneumothorax patient was given lovenox mg sq vitals prior to transfer ra upon arrival to the floor patient reports pain is persistent worse with inspiration worse when lying on affected side denies palpitations lightheadedness chest tightness chest pain notably denies long plane car rides recent surgery or immobility last within the year had breast bx that was negative for malignancy per pt report last pap smear years ago wnl per pt no prior cervical bx no weight loss fevers chills night sweats follows with endocrinologist at for her hypothyroidism s p thyroidectomy had bone scan notable for osteoporosis does not have routine imaging for thyroid malignancy follow up no hormonal use never smoker review of systems per hpi point ros reviewed and negative unless stated above in hpi past medical history gerd hiatal hernia macular degeneration papillary thyroid ca s p partial thyroidectomy hypothyroidism high cholesterol social history family history father had disease mother had breast cancer and dementia one daughter has primary biliary cholangitis no blood clots pe dvt father was on for unknown indication physical exam admission exam vital signs ra general alert oriented no acute distress heent sclerae anicteric mmm oropharynx clear eomi perrl neck supple jvp not elevated no lad cv tachycardic regular normal s1 s2 no murmurs rubs gallops lungs clear to auscultation bilaterally no wheezes rales rhonchi no chest wall tenderness abdomen soft non tender non distended bowel sounds present no rebound or guarding gu no foley ext warm well perfused pulses no edema neuro cnii xii intact strength upper lower extremities grossly normal sensation reflexes bilaterally gait deferred discharge exam vital signs t98 bp ra general alert oriented no acute distress heent sclerae anicteric mmm oropharynx clear eomi perrl neck supple jvp not elevated no lad cv tachycardic regular normal s1 s2 no murmurs rubs gallops lungs decreased breath sounds in rll otherwise clear to auscultation bilaterally no wheezes rales rhonchi posterior chest wall tender to palpation abdomen soft non tender non distended bowel sounds present no rebound or guarding gu no foley ext warm well perfused pulses no edema neuro cnii xii intact strength upper lower extremities grossly normal sensation reflexes bilaterally gait deferred pertinent results admission labs 15pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 15pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 15pm blood ptt 15pm blood glucose urean creat na k cl hco3 angap 15pm blood alt ast alkphos totbili 15pm blood lipase 15pm blood ctropnt probnp 30pm blood d dimer imaging cta chest segmental and subsegmental pulmonary emboli within the right lower lobe associated with pulmonary infarction in the peripheral anterior aspect of the right lower lobe no ct evidence for right heart strain small right pleural effusion cxr wedge shaped opacity within the periphery of the right lower lobe concerning for pulmonary infarction and further assessment with chest cta is recommended to evaluate for pulmonary embolism no pneumothorax discharge labs 15pm 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 alt ast ld ldh alkphos totbili 10am blood ctropnt 10am blood albumin calcium phos mg 10am blood tsh brief hospital course mrs is a year old female with a history of papillary thyroid carcinoma s p partial thyroidectomy in gerd and hiatal hernia who presented to the ed with ruq abdominal flank and right sided posterior chest wall pleuritic pain found to have rll segmental and subsegmental pes with associated rll pulmonary infarction active issues segmental and subsegmental pes patient presented with ruq and right posterior chest wall pain which was noted to be pleuritic in nature and worsened with inspiration initial cxr was concerning for a wedge like opacity within the periphery of the right lower lobe concerning for pulmonary infarction cta chest revealed segmental and subsegmental pes in the right lower lobe accompanied with pulmonary infarction in the peripheral anterior aspect of the right lower lobe patient had no evidence of right heart strain and cardiac markers troponin and bnp were negative underlying etiology of forming a vte is unclear at this time patient does not endorse recent history of being immobile and further denies any medications associated with formation of pe she has a history of papillary thyroid cancer years prior but is s p thyroidectomy her age appropriate cancer screening includes regular colonoscopies with a known history of polyps but last colonoscopy in was within normal pt was recommended f u in years also up to date on mammography and pap smears patient was treated as an unprovoked pe and was initiated on lovenox therapy and transitioned to rivaroxaban for month course for unprovoked pe she will be seen as an outpatient by hematology oncology to assess etiology of pe and complete a hypercoagulable workup transitional issues pt was started on a month course of rivaroxaban for unprovoked segmental and subsegmental pe with associated pulmonary infarct patient will take rivaroxaban 15mg bid for days start date end date and then transition to rivaroxaban 20mg once daily for months end date she will further followup with her pcp and outpatient hematologist for further hypercoagulable workup to guide length of therapy please readdress the length of anticoagulation required with rivaroxaban pending outpatient workup with hem onc please ensure patient is compliant with taking rivaroxaban daily to prevent future blood clots pt will benefit from f u with endocrinologist to consider repeat thyroid imaging including thyroid u s as well as tsh ft4 to ensure no evidence of recurrence of her thyroid ca and to determine if patients thyroid cancer history is related to development of a pe pt had incidentally found cholelithiasis noted on ct imaging however had normal lfts on this admission pt will benefit from repeating lfts if pt becomes symptomatic in the future medications on admission the preadmission medication list is accurate and complete famotidine mg po daily simvastatin mg po qpm levothyroxine sodium mcg po daily alprazolam mg po qhs prn anxiety insomnia discharge medications acetaminophen mg po q6h prn pain mild rx acetaminophen mg tablet s by mouth every hours disp tablet refills rivaroxaban mg po bid duration days dose of please take 15mg twice daily for weeks then switch to dose of rx rivaroxaban mg tablet s by mouth twice daily disp tablet refills rivaroxaban mg po daily dose of please start 20mg daily after complete weeks of 15mg twice daily rx rivaroxaban mg tablet s by mouth daily disp tablet refills alprazolam mg po qhs prn anxiety insomnia famotidine mg po daily levothyroxine sodium mcg po daily simvastatin mg po qpm discharge disposition home discharge diagnosis pulmonary embolism segmental and subsegmental pe discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear presented to the ed with right flank and right upper abdominal pain accompanied with right sided posterior chest wall pain that worsened with inspiration were assessed with labs and imaging and a ct scan of your chest showed several pulmonary emboli as well as an associated pulmonary infarction a damaged area of the lung due to lack of blood flow due to the above finding of a pulmonary embolism and pulmonary infarction were admitted to the inpatient service where were assessed with labs and monitored on telemetry had no difficulty maintaining your oxygen saturation and your pain was well controlled while admitted to the inpatient service were transitioned from lovenox to rivaroxaban a medication to prevent further development of blood clots in your lungs or elsewhere in your body will readdress how long need to be on your rivaroxaban with your outpatient primary care physician and outpatient hematologist however will likely continue rivaroxaban for a minimum of months please ensure that take your prescribed medications as instructed below and ensure that take this medication every day to prevent future clots please also followup at the appointments noted below that have been arranged on your behalf it was a pleasure being involved in your care your care team followup instructions

name unit admission date discharge date date of birth sex f service psychiatry allergies known allergies adverse drug reactions attending chief complaint i wasn t thinking clearly major surgical or invasive procedure none history of present illness per admitting physician ms is a year old pregnant female gestational age of 2days with history of bipolar ii disorder anxiety and trauma with one prior psychiatric hospitalization years ago in setting of suicide attempt by who was brought in to the ed on a from her outpatient psychiatrist s office due to si with plan to overdose on otc medications ms reports worsening depression and anxiety due to numerous psychosocial stressors she described her pregnancy as a big stressor because she is not able to return to school to finish her associate s degree she described additional stress from working for a and having a very high workload with long hours she does not feel supported by the staff at the furthermore she has had daily nausea and vomiting since becoming pregnant with inability to eat or even take dietary supplements overall she stated that she feels the pregnancy is a step back in her life she reports experiencing severe hopelessness and si with plan to overdose on naproxen yesterday and today upon further discussion she expressed hi towards the fetus i thought that if i do that the baby will go away she reports that she is still experiencing those thoughts and that she was worried about acting on them i don t want to make a mistake she described that she avoids keeping medications in the house due to fear of attempting suicide the fear is related to her mother s history of multiple sas and patient s own sa from years ago she describes that she has bottle of naproxen at home ms described that her si was worsened significantly by a conflict with her mother yesterday when her mother said some hurtful things which triggered me to back when i was suicidal also described stress from needing to move to a new apartment in patient describes weeks of not being able to fall asleep until am ruminating about whether she would finish school if she would be a good mother feeling tired with amotivation poor concentration and inability to go to work not been at work since had other work interruptions in past weeks she also reports anhedonia stating that the only thing that she looks forward to is finishing her associate s degree does not enjoy anything anymore and is not looking forward to having her baby she also reported poor appetite saying she eats because i have to eat she describes losing 45lbs from 145lbs to 100lbs years ago due to depression while being in an abusive relationship denies significant weight loss currently stating that she weighs 115lbs and that her obgyn is not concerned about the weight she described repeated visits to for iv fluids due to significant nausea and vomiting throughout the weeks of pregnancy however patient also reported that yesterday she was she was happy energetic was around family had a photo shoot to announce her pregnancy then she went home yesterday had the fight with her mother and began experiencing si hi in the ed ms received the following medications lorazepam 25mg po prenatal tab po pyridoxine 25mg po folic acid 1mg po on interview today the pt states that she has been feeling better since arrival in the ed of arrival she says yesterday i came in because i was thinking of taking a bottle of naproxen i didn t know if it would hurt me more or the baby she says she didn t care who she hurt i just knew i wasn t safe because i was going to hurt one of us she says she feels better in the hospital because people are taking care of me in her day to day life she feels she takes care of everyone else her mother her boyfriend and people at the where she works it feels good to be taking care of she cites a stressful conversation with her mother yesterday that made her feel really bad when her mother said she would never see her unborn child and that she would never act as its grandmother it really hurt she has also been stressed about the baby and the impact it will have on her schooling i worry all the time about how i will do internships and finish my classes i have put so much time into it the pt currently denies si and desire to hurt her baby seeing the ultrasound today made me feel better seeing the baby moving around she denies current symptoms of mania ah vh or paranoia she does endorse a sense of hypervigilance on the unit i m just really aware of what is going on and what people are doing i had bad things happen to me at and i ve heard my mom talk about things that happened to her she says while at she had issues with roommate smuggling in drugs she told staff at the time and being in that position made her feel unsafe she says that she feels comfortable going to staff with any issues that come up while she is here she endorses months of decreased sleep fatigue anhedonia and decreased concentration prior to hospitalization past medical history prior diagnoses bipolar ii disorder anxiety trichotillomania hospitalizations years ago partial hospitalizations years ago after discharge from inpatient unit at another php in a few months later due to recurrent depression psychiatrist had first appointment with psychiatry at on with dr whom she saw again today before being sent to the ed she reports that last week on olanzapine but patient was reluctant due to pregnancy she called him again yesterday when she became concerned about her safety prior to that used to see at in last saw in therapist at in last saw in had to switch providers to because she lost insurance due to her income increasing she found the therapy very helpful in the past and states that it contributed to her maintaining stable mood medication trials patient reports trialing psychiatric medications in the past can only remember olanzapine but always discontinues them due to side effects last time she trialed psychotropic medications was in olanzapine she discontinued it due to sedation trials denies suicide attempts at age cut right wrist with kitchen knife but was superficial cut called best team the next day and went to where she also attended after discharge since then has been keeping herself very busy which prevents her from thinking self injurious behavior harm to others denies trauma abusive relationship years ago with past boyfriend including emotional physical and sexual trauma also described being kicked out of mother s home at age and being homeless for some time access to weapons denies social history born raised born in moved to at months and with her mother and oldest sister who is year older relationship status children currently in a relationship with her boyfriend the father of the child primary supports mother though they have a strained relationship has other supports older sister grandfather stepfather friends but none of them are as close as her mother lives in own apartment in used to live with boyfriend but asked him to move out a few months ago because i needed my space he now lives with his own mother patient lived with mother until age then mother kicked her out so patient lived in a shelter then got her own apartment education graduated high school and was enrolled at for associate s degree in human services but had to put studies on hold years ago because of her depression and to take care of family she reports that she needs to live close to her mother because she worries her mother will attempt suicide again she still enjoys school has semesters left to complete her degree at plans to pursue bachelor s and phd after that and to become a currently works in at the in worked at the prior to that spiritual identifies as catholic but says that i stopped going to church a long time ago explained that this was years ago when she was in the abusive relationship family history psychiatric diagnoses mother with bipolar disorder older sister with depression use disorders father with alcohol and substance use suicide attempts completed suicides mother attempted suicide multiple times via od cutting multiple inpatient hospitalizations for mother physical general heent normocephalic atraumatic dry mucous membranes oropharynx clear supple neck scleral icterus cardiovascular regular rate and rhythm s1 s2 heard murmurs rubs gallops distal pulses intact throughout pulmonary increased work of breathing lungs clear to auscultation bilaterally wheezes rhonchi rales abdominal pregnant non distended bowel sounds normoactive tenderness to palpation in all quadrants guarding rebound tenderness extremities warm and well perfused edema of the limbs skin rashes or lesions noted neurological cranial nerves i olfaction not tested ii perrl to mm both directly and consentually brisk bilaterally vff to confrontation iii iv vi eomi without nystagmus vii 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 abnormal movements tremor strength throughout sensory deficits to fine touch throughout 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 moyb with errors orientation oriented to person time place psych unit situation executive function go luria trails fas not tested memory registration spontaneous recall after min long term grossly intact fund of knowledge consistent with education intact to last presidents calculations quarters thinks about for a minute and calculates on fingers abstraction don t judge a book by its cover you have to get to know someone before you judge them visuospatial not assessed language fluent speaker paraphasic errors appropriate to conversation mental status appearance appears stated age well groomed wearing hospital gown long artificial fingernails behavior sitting in chair appropriate eye contact psychomotor slowing present attitude cooperative engaged help seeking mood i m feeling better i don t know how i feel affect mood congruent blunted dysthymic appropriate to situation speech normal rate muted volume and normal prosody thought process linear coherent goal oriented loose associations thought content safety denies current si hi delusions evidence of paranoia etc obsessions compulsions evidence based on current encounter hallucinations denies avh not appearing to be attending to internal stimuli insight limited though pt is able to name number of stressors and elements of current situation that have made her feel safer judgment limited thoughts of hurting self and baby yesterday but help seeking called psychiatrist pertinent results 50pm urine bnzodzpn neg barbitrt neg opiates neg cocaine neg amphetmn neg oxycodn neg mthdone neg 20pm glucose urea n creat sodium potassium chloride total co2 anion gap 20pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 20pm neuts monos eos basos im absneut abslymp absmono abseos absbaso 20pm plt count 12am blood triglyc hdl chol hd ldlcalc 12am blood hba1c eag legal safety on admission the patient signed a conditional voluntary agreement section on and remained on that status throughout their admission at that time patient was deemed to be at risk of harm to self others due to suicidal thoughts and worsening depressed mood anhedonia and neurovegetative symptoms she was placed on minute check status on admission and remained on that level of observation throughout while being unit restricted upon suicide risk assessment evaluation safe t risk was deemed moderate to low once patient retracted all suicidal statements appeared future oriented help seeking and was medication adherent psychiatric bipolar ii disorder current episode depressed unspecified anxiety disorder ms is a year old pregnant female g1p0 gestational age of weeks with hx bipolar ii disorder and family hx bpad anxiety trauma with one prior psychiatric hospitalization years ago in setting of suicide attempt by cutting who was brought in to the ed on a from her outpatient psychiatrist s office due to si with plan to overdose on nsaids patient endorsed depressed mood with intrusive egodystonic suicidal thoughts in the setting of various psychosocial stressors including physical discomfort secondary to pregnancy vomiting financial stressors work related stressors impact upon her academics and subsequent academic stressors from performing poorly in school and interpersonal conflict with her mother in context of hx of physical and emotional abuse from her mother on initial presentation patient appeared to be isolative was not seen often participating in other ot lead group sessions or within the milieu her isolated behavior was also associated with severe anxiety impaired sleep poor appetite and frequent anxious ruminative thoughts that were distressing and often oriented around her future however during the course of this admission patient started leaving her room more frequently was more visible in the milieu and was willing to develop new coping mechanisms that she had learned during group therapy sessions she expressed interest in continuing therapy in the outpatient setting and wanted to utilize her admission as an opportunity to start new medications while developing new coping mechanisms as such patient was started on abilify mg nightly which she tolerated with reported adverse effects she was additionally offered vistaril mg q4h prn for anxiety and nausea as she suffered from hyperemesis gravidarum and had difficulty tolerating her perenatal vitamins folic acid supplementation while admitted patient additionally reported that her mood had improved and she appeared more future oriented with an intact sense of self worth she did note that she had multiple conversations with her boyfriend who reported that he would help support her financially so that she would not have to return to work if she decided that would be most beneficial to her she reported that work was a major stressor for her given perceived lack of support from the administration mental status exam initially was significant for monotonous soft speech dysthymic and constricted though reactive affect with psychomotor slowing concerning for neurovegative symptoms patient reported impaired sleep and concentration though cognitive exam was intact prior to discharge patient reported improved ms endorses improvement in mood appetite and resolution of suicidal thoughts she is future oriented and demonstrates a number of protective factors including interest in parenting pregnancy preparedness classes continued follow up with outpatient psychiatrist and treatment with aripiprazole while she continues to have a strained relationship with her mother she identifies her sister and boyfriend as strong social supports diagnostically presentation is concerning for bipolar ii disorder current episode depressed severe patient s presentation is further complicated by pregnancy patient of note initially presented with active suicidal ideation with plan to harm herself but has since retracted initial suicidal statements appears more future oriented and willing to develop new coping strategies she appears help seeking and would benefit from continued outpatient therapy and medication management we arranged for outpatient partial program treatment at substance use disorders patient has hx of cannabis use but stopped smoking cannabis when she found out she was pregnant longer actively uses substances we encouraged development and maintenance of positive coping mechanisms in lieu of substance use follow up with pcp and program for continued substance use counseling medical r flank pain resolved prior to discharge patient reported right sided flank pain with soreness worsened by cough and improved with tylenol and heating pad administration focal concerns on exam cva tenderness treated with tylenol mg q6h prn for moderate to severe pain heating pad prn viral upper respiratory infection patient reported cough and congestion x1 week offered saline spray prn for nasal congestion offered cepecol lozenges prn and guanfesein prn vomiting pt states that she vomited in ed and continues to experience nausea bmp ordered to monitor for signs of metabolic derangement which was within normal limits intermittent association with food and water continues to occur with folate and b6 does not appear to be consistent with hyperemesis gravidarum and appears more anxiety related provided iv fluids and anti nausea medications which improved allowing patient to tolerate food prior to discharge ob to continue to monitor weight and appetite on discharge pregnancy per ob note regular fetal monitoring was not required continued folic acid po daily continued prenatal vitamins next ultrasound for at appointment psychosocial groups milieu the patient was encouraged to participate in the various groups and milieu therapy opportunities offered by the unit initially patient was minimally interactive in group sessions she exhibited isolative and avoidant behaviors secondary to hypersomnolence pain and discomfort along with anhedonic sx during the course of her hospitalization however patient eventually began participating more frequently in group sessions she demonstrated improvement in insight participated more often in coping skills group and her affect appeared brighter collateral information and family involvement patient has a case manger from through to discuss resources support upon discharge interventions medications aripiprazole psychotherapeutic interventions individual group and milieu therapy coordination of aftercare php referral partial hospital program women s program p f start date at 15am program hours m f from a m to p m breakfast and lunch are provided behavioral interventions group therapy coping skills guardianships none pcp mmf aripiprazole informed consent the team discussed the indications for intended benefits of and possible side effects and risks of starting this medication would consider specifically mention discussing black box warnings very dangerous side effects and risks and benefits of possible alternatives including not taking the medication with this patient we discussed the patient s right to decide whether to take this medication as well as the importance of the patient s actively participating in the treatment and discussing any questions about medications with the treatment team the patient appeared able to understand and consented to begin the medication risk assessment prognosis on presentation the patient was evaluated and felt to be at an increased risk of harm to herself and or others based upon active suicidal ideation her static factors noted at that time include history of suicide attempts history of abuse chronic mental illness age marital status single family history of suicide attempt we addressed the following modifiable risk factors with daily motivational interviewing encouragement of therapy led groups medication adjustment and arrangement of with outpatient providers with resolution of the following suicidal ideation medication noncompliance poorly controlled mental illness hopelessness limited social supports feeling trapped patient has the following protective factors which decrease risk of harm to self protective factors help seeking nature sense of responsibility to family pregnancy irritability agitation rage anger revenge good problem solving skills positive therapeutic relationship with outpatient providers history of substance use disorder overall based on the totality of our assessment at this time the patient is not at an acutely elevated risk of self harm nor danger to others medications on admission the preadmission medication list is accurate and complete prenatal vitamins tab po daily pyridoxine mg po tid nausea vomiting folic acid mg po daily discharge medications acetaminophen mg po q6h prn pain mild fever aripiprazole mg po qhs mood disorder rx aripiprazole abilify mg tablet s by mouth at bedtime disp tablet refills hydroxyzine mg po q4h prn anxiety nausea rx hydroxyzine hcl mg mg by mouth every hours as needed disp tablet refills polyethylene glycol g po daily prn constipation first line pyridoxine mg po tid prn nausea vomiting folic acid mg po daily prenatal vitamins tab po daily discharge disposition home discharge diagnosis bipolar disorder type ii current episode depressed unspecified anxiety disorder discharge condition mental status appearance female appearing slightly older than stated age well groomed good hygiene appropriate eye contact psychomotor agitation or retardation attitude cooperative engaged friendly mood better affect congruent euthymic constricted reactive tearful at times appropriate to situation speech normal rate volume and tone thought process linear coherent goal oriented loose associations rumination on vomiting thought content safety denies si hi delusions evidence of paranoia etc obsessions compulsions evidence based on current encounter hallucinations denies avh not appearing to be attending to internal stimuli insight limited judgment fair cognition wakefulness alertness awake and alert attention not formally assessed but attentive to interview orientation oriented to person time place situation executive function not assessed memory not formally assessed but intact to interview language native speaker paraphasic errors appropriate to conversation discharge instructions please follow up with all outpatient appointments as listed take this discharge paperwork to your appointments unless a limited duration is specified in the prescription please continue all medications as directed until your prescriber tells you to stop or change please avoid abusing alcohol and any drugs whether prescription drugs or illegal drugs as this can further worsen your medical and psychiatric illnesses please contact your outpatient psychiatrist or other providers if you have any concerns please call or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers it was a pleasure to have worked with you and we wish you the best of health followup instructions

name unit no admission date discharge date date of birth sex m service orthopaedics allergies almonds attending chief complaint left knee osteoarthritis pain major surgical or invasive procedure left total knee arthroplasty history of present illness year old male w left knee osteoarthritis pain who failed conservative measures now admitted for left total knee arthroplasty past medical history dyslipidemia osa tested positive years ago seasonal allergies headaches occasional h o kidney stones bph w elevated psa bcc s p right knee meniscectomy left knee meniscectomy right l4 discectomy l5 s1 laminectomy fusion right shoulder surgery lithotripsy vasectomy tonsillectomy age 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 36am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 45am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 28am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 28am blood glucose urean creat na k cl hco3 angap 28am blood calcium phos mg 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 unremarkable 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 please use walker or crutches wean as able mr is discharged to home with services in stable condition medications on admission atorvastatin mg po qpm tamsulosin mg po qhs vitamin d unit po daily fish oil omega mg po bid multivitamins tab po daily discharge medications acetaminophen mg po q8h aspirin mg po bid docusate sodium mg po bid oxycodone immediate release mg po q4h prn pain pantoprazole mg po q24h senna mg po bid atorvastatin mg po qpm multivitamins tab po daily tamsulosin mg po qhs vitamin d unit po daily held fish oil omega mg po bid this medication was held do not restart fish oil omega until aspirin course completed discharge disposition home with service facility discharge diagnosis left knee osteoarthritis 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 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 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 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 two crutches or walker wean assistive device as able mobilize rom as tolerated no strenuous exercise or heavy lifting until follow up appointment physical therapy wbat lle no range of motion restrictions 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 staple removal and replace with steri strips at follow up visit followup instructions

name unit no admission date discharge date date of birth sex m service orthopaedics allergies almonds attending chief complaint left knee arthrofibrosis major surgical or invasive procedure left knee manipulation under anesthesia history of present illness year old male with history of l tka with left knee arthrofibrosis who presents for left knee manipulation under anesthesia past medical history dyslipidemia osa tested positive years ago seasonal allergies headaches occasional h o kidney stones bph w elevated psa bcc s p right knee meniscectomy left knee meniscectomy right l4 discectomy l5 s1 laminectomy fusion right shoulder surgery lithotripsy vasectomy tonsillectomy age 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 stable thigh soft no calf tenderness strength silt nvi distally toes warm brief hospital course the patient was admitted to the orthopaedic surgery service and was taken to the operating room for above described procedure please see separately dictated operative report for details the surgery was uncomplicated and the patient tolerated the procedure well postoperative course was remarkable otherwise pain was controlled with an epidural post operatively it was discontinued on pod and he was transitioned to oral pain medications the foley was discontinued on pod and the patient was able to void independently the patient was seen by physical therapy 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 pain was adequately controlled on an oral regimen the operative extremity was neurovascularly intact the patient s weight bearing status is weight bearing as tolerated on the operative extremity wean assistive devices as able mr is discharged to home with outpatient physical therapy in stable condition medications on admission tamsulosin mg po bid atorvastatin mg po qpm vitamin d unit po daily multivitamins tab po daily discharge medications acetaminophen mg po q8h rx acetaminophen mg tablet s by mouth every hours disp tablet refills oxycodone immediate release mg po q4h prn pain moderate no drinking alcohol or driving while taking this medication rx oxycodone mg tablet s by mouth every hours disp tablet refills atorvastatin mg po qpm multivitamins tab po daily tamsulosin mg po bid vitamin d unit po daily discharge disposition home discharge diagnosis left knee arthrofibrosis 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 activity weight bearing as tolerated on the operative extremity wean assistive device as able mobilize rom as tolerated no strenuous exercise or heavy lifting until follow up appointment followup instructions

name unit no admission date discharge date date of birth sex f service obstetrics gynecology allergies cipro ceclor reglan toradol morphine attending chief complaint pre term labor abruption major surgical or invasive procedure low transverse c section physical exam physical exam on discharge vs afebrile vss neuro psych nad oriented x3 affect normal heart rrr lungs cta b l abdomen soft appropriately tender fundus firm incision c d i pelvis minimal bleeding extremities warm and well perfused no calf tenderness no edema pertinent results 22am wbc rbc hgb hct mcv mch mchc rdw rdwsd 22am plt count 22am ptt 22am 14am wbc rbc hgb hct mcv mch mchc rdw rdwsd 14am plt count 38pm other body fluid fetalfn positive 15pm urine color yellow appear hazy sp 15pm urine blood neg nitrite neg protein tr glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg 15pm urine rbc wbc bacteria few yeast none epi trans epi 15pm urine amorph rare 15pm urine mucous rare brief hospital course on ms was admitted to antepartum service for pre term labor and placental abruption she underwent a low transverse cesarean section with an estimated blood loss and her hematocrit was monitored closely post operatively her pain was controlled with dilaudid pca which was transitioned to oral dilaudid acetaminophen and ibuprofen she was also seen by the chronic pain service during her hospitalization she was continued on her home levothyroxine during her hospitalization she was offered her home subutex but declined by postpartum day she was tolerating a regular diet ambulating independently and pain was controlled with oral medications she was afebrile with stable vital signs she was then discharged home in stable condition with postpartum outpatient follow up scheduled medications on admission the preadmission medication list is accurate and complete buprenorphine mg sl daily prenatal vitamins tab po daily levothyroxine sodium mcg po daily discharge medications docusate sodium mg po bid prn constipation rx docusate sodium colace mg capsule s by mouth twice a day disp capsule refills hydromorphone dilaudid mg po q6h prn pain severe pain rx hydromorphone dilaudid mg tablet s by mouth q hr disp tablet refills ibuprofen mg po q6h rx ibuprofen mg tablet s by mouth q hours disp tablet refills lorazepam mg po q6h prn muscle spasm rx lorazepam ativan mg by mouth q disp tablet refills levothyroxine sodium mcg po daily prenatal vitamins tab po daily discharge disposition home discharge diagnosis pregnancy delivered hypothyroid h o opiate abuse anxiety discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions routine post partum pt was given post op narcotics and told she cannot get refills except from followup instructions

name unit no admission date discharge date date of birth sex f service obstetrics gynecology allergies cipro ceclor reglan toradol morphine attending chief complaint pelvic cramping rule out reterm labor rule out short cervix major surgical or invasive procedure none history of present illness 19w2d with prior history of preterm delivery at 29w3d due to abruption presents with irregular contractions patient states that she has been experiencing irregular contractions lasting one minute for one week the contractions are associated w back pain and pelvic pain which subsides once contractions this morning she noted pink spotting thus she decided to present she denies any recent vaginal intercourse abdominal trauma changes in vaginal discharge of note her last tvus was on which showed a cl cm she endorses fm and denies vb lof she feels nervous that her cervix is shorter and she is having preterm labor she denies any ha f c n v abdominal pain rashes last meal hours ago all celcor childhood cipro itching throat swelling toradol rash morphine choking sensation past medical history pnc by ivf dating labs a rh neg ri rpr neg hbsag neg hiv neg gbs unk screening low risk era ffs n a glt n a us n a issues small subchorionic hematoma noted on u s at 6w5d no vaginal bleeding plan follow up with nt u s hx preterm delivery with repeat ltcs at weeks for twins followed for short cervix preterm contractions both babies are doing very well and meeting milestones s p consult im progesterone week for prevention of recurrent preterm birth however pt opted to start vaginal progesterone 12weeks hx opioid use on buprenorphine qd hypothyroidism levothyroxine 75mcg qd last tsh on ghsv suppression 36wks ob g1 sab g2 c s at term 38w0d g3 c s at 29w3d abruption mono di twins pmh opiate dependence anxiety hypothyroidism psh c s x lsc x ovarian cystectomy appendectomy loa exploratory laparotomy ruptured hemorrhagic cyst cholecystectomy mini laparotomy social history family history non contributory physical exam gen a o nad cv rrr resp ctab abd bs soft nt nd no rebound or guarding ext calves nontender bilaterally no c c e pelvic normal vulva anatomy vagina w normal discharge no bleeding noted cervix appears visually closed sve pt declined fht 140s bedside tvus cervical length measuring cm unchanged w fundal pressure pertinent results 08pm other body fluid ct neg ng neg trich neg brief hospital course admitted for observation lower abdominal cramping resolved u s cephalic normal fluid cervical length 4cm no evidence abruption follow up u s prelim read cl 7cm per review with dr discharge instructions reviewed d c home with follow up on with primary md and with u s medications on admission meds levothryxoine 100mcg daily subtex 8mg tid pnv vaginal progesterone bid discharge medications buprenorphine mg sl tid levothyroxine sodium mcg po daily prenatal vitamins tab po daily discharge disposition home discharge diagnosis preterm contractions discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions per instruction sheet followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies tylenol nsaids non steroidal anti inflammatory drug attending chief complaint shortness of breath lethargy weakness poor appetite major surgical or invasive procedure none history of present illness mr is a y o man with pmhx of newly diagnosed lung ca who presents from home with days of progressive dyspnea he states that he has been feeling badly for weeks now since diagnosis of lung cancer nearly a month ago he endorses poor po intake due to mild nausea but mostly no appetite he has tried dronabinol terrible side effects of diarrhea and cramping as well as marijuana now no drive to even use that he endorses nearly pounds of weight loss over past few months more acutely he for the past few days has had increasing shortness of breath without significant cough or sputum production he denies any fevers or chills does have some substernal pressure that is worse with coughing no diagnosed lung disease apart from lung cancer but does have decades of tobacco use and used to work in so feels like had lots of exposure to potential toxins he feels that he should have presented to ed multiple days ago but did not have the drive to finally pushed by mother and girlfriend to come in of note patient most recently saw dr atrius oncology on at which point he was planned to start chemotherapy on he did take dexamethasone as instructed he has not had any chemotherapy yet detailed oncologic history as below in the ed initial vitals were ra exam notable for diffuse expiratory wheezing bilaterally increased work of breathing with subcostal and supraclavicular respiratory muscle involvement labs notable for wbc flu a b negative imaging cxr without acute process known lung mass duonebs and diazepam was given upon arrival to the floor patient endorses the above history he feels weak anorexia hasn t slept in many days he would like a diazepam to help him sleep feels breathing is still not at baseline has some mild chest tightness but no other symptoms review of systems as per hpi past medical history newly diagnosed lung cancer as below history of alcohol abuse history of substance abuse atrial septal defect stroke small vessel in without residual deficits on aggrenox tobacco dependence hypercholesteremia insomnia unspecified oncologic history per atrius pathology results cervical node biopsy fna non diagnostic left axillary node biopsy fna negative eus adrenal gland core biopsy poorly differentiated carcinoma with extensive necrosis note immunohistochemical stains are performed the tumor cells are positive for cytokeratin cocktail ae1 cam5 and ck7 ck20 ttf napsin p40 and inhibin are negative the findings are not specific for the origin of this tumor clinical imaging correlation is recommended social history family history no family history of cancer physical exam admission physical exam vital signs ra general chronically ill appearing tired but in nad heent nc at wearing glasses dry mucous membranes tongue midline on protrusion neck supple symmetric cardiac rrr no m r g lungs air movement with poor effort is present but poor in all fields no crackles rhonchi or wheezes can be appreciated in this context no increased work of breathing and speaking in full senteces abdomen soft mildly tender on palpation diffusely non rigid no r g bs extremities thin wwp no pitting edema distal pulses intact neurologic alert and oriented moving all extremities symmetric smile sensation to light touch symmetric and intact in all divisions of cn5 ue torso strength in b l ue able to lift both legs up against gravity and downward pressure b l skin no bruises or petechiae discharge physical exam vital signs t po bp hr rr o2 ra general sitting up on a chair eating breakfast no acute distress head normocephalic atraumatic teeth and gums normal lungs poor air movement throughout all lung fields decreased breath sounds no increased work of breathing speaks in full sentences heart regular rate and rhythm s1 s2 normal abdomen soft non tender normal bowel sounds extremities warm well perfused no edema neuro alert and oriented ue strength grossly normal strength normal sensation grossly intact throughout all extremities pertinent results admission labs 03pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 03pm blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 50am blood ptt 03pm blood glucose urean creat na k cl hco3 angap 03pm blood ck cpk 50am blood alt ast ld ldh alkphos totbili 03pm blood ck mb ctropnt 50am blood albumin calcium phos mg 50am blood cortsol 12pm blood po2 pco2 ph caltco2 base xs 12pm blood lactate 35am urine color yellow appear cloudy sp 35am urine blood neg nitrite neg protein tr glucose neg ketone bilirub neg urobiln neg ph leuks neg 35am urine rbc wbc bacteri none yeast none epi microbiology time taken not noted log in date time pm stool consistency not applicable source stool final report c difficile dna amplification assay final negative for toxigenic c difficile by the cepheid nucleic acid amplification assay reference range negative imaging cxr no acute cardiopulmonary process re demonstration of left apical mass better assessed on previous ct upper lobe predominant emphysema ct chest growing left upper lobe lung mass at least rib metastases responsible for pathologic fractures one healed and not healed were present in no new metastases coronary atherosclerosis findings below the diaphragm including large bilateral adrenal masses will be reported separately ct abdomen pelvis x mm rounded soft tissue nodule in the left buttock deep to the gluteus musculature is new from the recent prior exam of worrisome for soft tissue metastasis bilateral heterogeneously hypoenhancing adrenal metastases are significantly larger since now measuring up to cm on the right and cm on the left previously up to and cm respectively please see separate report for intrathoracic findings from same day ct chest discharge labs 10am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 10am blood glucose urean creat na k cl hco3 angap 10am blood calcium phos mg brief hospital course mr is a male with a smoking history and recent diagnosis of lung cancer in with metastasis to adrenal glands who presents for failure to thrive leukemoid reaction and progression of his metastatic disease failure to thrive in the setting of progression of his metastatic lung cancer mr has been experiencing a decline in his ability to care for himself notable weight loss of 20lbs in the past few months decreased appetite exhaustion and decreased physical activity he has taken dronabinol in the past but experienced significant diarrhea and cramping initial concern for adrenal insufficiency due to adrenal metastases was reassured by am cortisol of patient was seen by physical therapy social work palliative care and nutrition palliative care recommended symptomatic treatment of his constipation with milk of magnesia and appetite stimulants were discussed consideration for dronabinol versus medical marijuana he should have a bowel movement at least once every three days if he does not we advised him to take milk of magnesia till he has a bowel movement patient declined any additional appetite stimulants at this time he did not want to be stoned during the day nutrition advised nutritional supplementation with ensure supplements at meals patient remained hemodynamically and clinically stable throughout his hospital stay ambulatory o2sat on discharge was leukemoid reaction patient presented with leukocytosis to which was a significant rise from his last cbc normal in though prior to diagnosis of his lung cancer clinically the patient did not appear infected no fever cough diarrhea infectious workup is negative to date blood cultures urine culture c diff cxr blood smear did not reveal any concern for a primary hematologic disorder and was consistent with a significant leukemoid reaction likely in the setting of his progressive metastatic lung cancer lung cancer metastatic presenting with fatigue general malaise poor appetite and worsening dyspnea in the setting of recent diagnosis of lung cancer ct abdomen and pelvis on this admission is concerning for progression of his adrenal metastasis and a new x mm rounded soft tissue nodule in the left buttock deep to the gluteus musculature concerning for soft tissue metastasis ct chest revealed growing left upper lobe lung mass after discussions with atrius oncology patient will be discharged to begin chemotherapy on as an outpatient he will start dexamethasone mg daily today for three days hyperlipidemia consider stopping statin given his shortened life expectancy versus time required for benefit of statin insomnia patient has longstanding insomnia and is prescribed diazepam 15mg qhs he noted that he frequently takes anywhere between per night he has not tried good sleep hygiene practices additionally his primary problem is maintenance of sleep not initiation so it would be helpful for him to try medicaitons for maintenance of sleep as he is slowly weaned off diazepam given his longstanding use of benzodiazepines for sleep transitional issues failure to thrive nutrition tried dronabinol in the past but experienced diarrhea and cramping medical marijuana was discussed as an appetite stimulant which he refuses at this time po supplementation with ensure shakes has been advised constipation patient has been advised to take milk of magnesia as needed if he is not experiencing bowel movements at least once every three days leukemoid reaction wbc on discharge was f up on pending blood and urine cultures lung cancer metastatic to adrenals ribs left buttock patient to begin chemotherapy on advised to take dexamethasone mg daily on the day prior day of day after chemotherapy start date end date insomnia advised slowly titrating off diazepam promotion of maintenance of sleep medications ambien not initiation of sleep continue to encourage good sleep hygiene discharge weight 4kg code full code for now contact mother medications on admission the preadmission medication list is accurate and complete diazepam mg po qhs prn insomnia anxiety dexamethasone mg po daily folic acid mg po daily prochlorperazine mg po q6h prn nausea ondansetron mg po q8h prn nausea multivitamins w minerals tab po daily oxycodone immediate release mg po daily prn pain moderate simvastatin mg po qpm dipyridamole aspirin cap po bid sildenafil mg po prn intercourse discharge medications milk of magnesia ml po q6h prn constipation rx magnesium hydroxide milk of magnesia mg ml ml by mouth every six hours refills dexamethasone mg po daily duration days diazepam mg po qhs prn insomnia anxiety dipyridamole aspirin cap po bid folic acid mg po daily multivitamins w minerals tab po daily ondansetron mg po q8h prn nausea oxycodone immediate release mg po daily prn pain moderate prochlorperazine mg po q6h prn nausea sildenafil mg po prn intercourse simvastatin mg po qpm discharge disposition home discharge diagnosis primary diagnoses failure to thrive leukemoid reaction secondary to progressive metastatic lung cancer constipation secondary diagnoses metastatic stave iv lung cancer hyperlipidemia insomnia discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr you were hospitalized at for weakness poor appetite decreased activity and exhaustion these symptoms are most consistent with your underlying lung cancer and the progression of the disease we have advised nutritional supplementation with ensure milk of magnesium for your constipation to be taken if you are not having a bowel movement every three days and physical therapy as tolerated imaging and labs are negative for an infection at this time you have an elevated white blood cell count a marker of inflammation or infection and in this case we think it is a reflection of the progression of your lung cancer as confirmed on imaging we have spoken with the oncology team at they would like you to start chemotherapy on you will take three days of dexamethasone to begin today and to end on please make sure to take your bowel regimen medication you should have a bowel movement atleast once every three days if you do not have a bowel movement by the third day please take milk of magnesia till you have a bowel movement it is important that you attend the follow up appointments listed below it was a pleasure taking care of you we wish you the best your team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies tylenol nsaids non steroidal anti inflammatory drug attending chief complaint flank pain major surgical or invasive procedure none history of present illness patient is a yo man wit newly diagnosed poorly differentiated metastatic lung cancer based upon a biopsy of an adrenal lesion followed by dr admitted with right flank and ruq abdominal pain and transient left leg discomfort and tingling past medical history newly diagnosed lung cancer as below history of alcohol abuse history of substance abuse atrial septal defect stroke small vessel in without residual deficits on aggrenox tobacco dependence hypercholesteremia insomnia unspecified oncologic history per atrius pathology results cervical node biopsy fna non diagnostic left axillary node biopsy fna negative eus adrenal gland core biopsy poorly differentiated carcinoma with extensive necrosis note immunohistochemical stains are performed the tumor cells are positive for cytokeratin cocktail ae1 cam5 and ck7 ck20 ttf napsin p40 and inhibin are negative the findings are not specific for the origin of this tumor clinical imaging correlation is recommended social history family history no family history of cancer physical exam vs po ra gen cachectic appearing in nad heent neck anicteric sclera mmm op clear neck supple heart rrr no m r g lungs ctab no wheezes rales or crackles symmetric expansion abd soft nt nd bs no rebound or guarding ext warm well perfused no pitting edema neuro alert and oriented fluent speech cn ii xii intact no focal deficits on strength testing strength with gross sensation intact pertinent results 52pm lactate 10pm urine hours random 10pm urine uhold hold 10pm urine color yellow appear clear sp 10pm urine blood neg nitrite neg protein tr glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg 10pm urine rbc wbc bacteria few yeast none epi trans epi 07am type art comments green top 07am lactate 01am glucose urea n creat sodium potassium chloride total co2 anion gap 01am alt sgpt ast sgot alk phos tot bili 01am lipase 01am albumin 01am wbc rbc hgb hct mcv mch mchc rdw rdwsd 01am neuts lymphs monos eos basos im absneut abslymp absmono abseos absbaso 01am plt count findings the liver appears normal in grayscale appearance and size without focal lesion of concern no biliary ductal dilation gallstones noted within the gallbladder though there is no evidence for acute cholecystitis sonographic sign is negative common bile duct measures up to mm the known right adrenal metastasis is visualized though better characterized on same day ct exam a simple appearing cyst is seen in the right kidney interpolar region measuring cm in diameter lymphadenopathy adjacent to the pancreas better assessed on same day ct no ascites impression cholelithiasis without evidence of cholecystitis right adrenal mass and enlarged peripancreatic nodes better assessed on same day ct exam impression no evidence of acute pulmonary embolism or aortic abnormality interval worsening and enlargement of retroperitoneal lymph nodes specifically with development of at least centrally necrotic lymph nodes along the posterior aspect of the pancreas slight interval increase in size of left gluteal soft tissue nodule since bilateral adrenal metastatic lesions are unchanged in size from but significantly larger than unchanged left upper lobe pulmonary mass brief hospital course yo m with poorly differentiated metastatic lung cancer with adrenal mets lymphadenopathy s p recent pemetrexed carboplatin who presented with r flank pain and episode of l leg numbness now resolved acute r flank pain work up as above and essentially negative except for cholelithiasis resolved after hrs cause unclear be side effect from chemotherapy be biliary colic as well ruq us without cholecystitis or evidence of obstruction imaging re assuring and not consistent with renal colic pancreatitis or referred pain follow up with oncology scheduled for day after discharge metastatic poorly differentiated lung cancer s p chemo on reviewed case with dr oncology cont folate lle numbness resolved possibly due to sciatica though no back pain metastatic dz to spine is also to be considered though pet imaging was negative and symptoms resolved on their own spontaneously one would expect persistent symptoms if there were a mass lesion outpatient follow up hypotension ivf given anxiety stable h o cva continued aggrenox medications on admission the preadmission medication list is accurate and complete diazepam mg po qhs prn insomnia anxiety dipyridamole aspirin cap po bid folic acid mg po daily multivitamins w minerals tab po daily ondansetron mg po q8h prn nausea oxycodone immediate release mg po daily prn pain moderate prochlorperazine mg po q6h prn nausea simvastatin mg po qpm sildenafil mg po prn intercourse dexamethasone mg po daily milk of magnesia ml po q6h prn constipation discharge medications diazepam mg po qhs prn insomnia anxiety dipyridamole aspirin cap po bid folic acid mg po daily milk of magnesia ml po q6h prn constipation multivitamins w minerals tab po daily ondansetron mg po q8h prn nausea oxycodone immediate release mg po daily prn pain moderate prochlorperazine mg po q6h prn nausea sildenafil mg po prn intercourse simvastatin mg po qpm discharge disposition home discharge diagnosis metastatic lung cancer discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted for evaluation of right sided pain and left leg numbness evaluation was negative your symptoms improved please stay well hydrated take your medications as prescribed and follow up with your oncologist as scheduled tomorrow followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies tylenol nsaids non steroidal anti inflammatory drug attending chief complaint abdominal pain major surgical or invasive procedure none history of present illness mr is a male with history of history of metastatic lung cancer currently on alimta carboplatin who presents with abdominal pain and constipation patient reports severe constipation last bowel movement about one week ago he has tried multiple stool softeners including colace senna milk of magnesia suppository and fleet enema without success he also continues to have back and rib pain he has been taking oxycodone and valium for pain he feels very weak and tired has had difficulty walking at home recently due to abdominal pain not eating well he was seen at urgent care where exam as notable for diffuse abdominal tenderness to palpation kub was unremarkable he had manual disimpaction with removal of small amount of stool he was referred to ed for further evaluation on arrival to the ed initial vitals were ra labs were notable for wbc pmns bands lymphs h h plt na bun cr lfts wnl ua negative he had ct abdomen pelvis which showed worsening metastatic disease and short segment of intussuscepted small bowel colorectal surgery was consulted and recommended no urgent surgical interventions he was given dilaudid 1mg iv valium 15mg po and 1l ns prior to transfer vitals were ra on arrival to the floor patient reports abdominal pain has improved reports back and rib pain he denies fevers chills night sweats headache vision changes dizziness lightheadedness weakness numbnesss shortness of breath cough hemoptysis chest pain palpitations nausea vomiting diarrhea hematemesis hematochezia melena dysuria hematuria and new rashes past medical history pet scan there is a x cm left upper lobe irregular soft tissue mass with significant increased fdg uptake concerning for malignancy with a few associated mildly avid left axillary lymph nodes there is a prominent cm left cervical level iia lymph node with increased fdg uptake concerning for metastatic focus there is a cm fdg avid soft tissue lesion at the level of the kidneys which may represent either an enlarged left para aortic lymph node or a left adrenal gland nodule recommend further evaluation with additional diagnostic ct imaging cm right adrenal nodule with mildly increased fdg uptake also incompletely evaluated on this low dose exam sigmoid diverticulosis prostamegaly renal cysts cervical node biopsy fna non diagnostic left axillary node biopsy fna negative eus adrenal gland core biopsy poorly differentiated carcinoma with extensive necrosis note immunohistochemical stains are performed the tumor cells are positive for cytokeratin cocktail ae1 cam5 and ck7 ck20 ttf napsin p40 and inhibin are negative the findings are not specific for the origin of this tumor head mri showed no evidence of intracranial metastatic disease at this time chronic right thalamic lacunar and left cerebellar infarcts admitted to with generalized weakness he received his first chemotherapy with carboplatin and pemetrexed took decadron premedication and is on folate supplementation admitted to with right flank and ruq pain imaging with abdominal ct and ruq us negative except for cholelithiasis resolved after hours past medical history history of alcohol abuse history of substance abuse atrial septal defect stroke small vessel in without residual deficits on aggrenox tobacco dependence hypercholesteremia insomnia social history family history no family history of cancer physical exam admission exam vs temp bp hr rr o2 sat ra general pleasant man in no distress lying in bed comfortably heent anicteric perll op clear cardiac rrr normal s1 s2 no m r g lung appears in no respiratory distress clear to auscultation bilaterally no crackles wheezes or rhonchi abd soft mild diffuse tenderness to palpation without rebound non distended normal bowel sounds ext warm well perfused no lower extremity edema erythema or tenderness neuro a ox3 good attention and linear thought cn ii xii intact strength full throughout sensation to light touch intact skin no significant rashes discharge exam vs ra i o x1 bm yesterday and x1 this morning general nad lying on his back in bed sleepy but able to open his eyes and converse with me heent anicteric sclerae op clear cardiac rrr normal s1 s2 no m r g lung clear to auscultation bilaterally no crackles wheezes or rhonchi abd nabs abdomen is soft nondistended mild diffuse tenderness to palpation worst in the luq today without rebound or guarding ext warm well perfused no lower extremity edema erythema or tenderness neuro a ox3 moves all four extremities spontaneously skin no significant rashes pertinent results admission labs 30pm urine hours random 30pm urine uhold hold 30pm urine color yellow appear clear sp 30pm urine blood neg nitrite neg protein tr glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg 30pm urine rbc wbc bacteria none yeast none epi 30pm urine amorph rare 30pm urine mucous rare 30pm glucose urea n creat sodium potassium chloride total co2 anion gap 30pm estgfr using this 30pm alt sgpt ast sgot alk phos tot bili 30pm lipase 30pm albumin 30pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 30pm neuts bands lymphs monos eos basos myelos absneut abslymp absmono abseos absbaso 30pm hypochrom occasional anisocyt poikilocy occasional macrocyt microcyt polychrom ovalocyt occasional burr occasional fragment occasional 30pm plt smr normal plt count pertinent imaging ct abdomen pelvis w contrast worsening metastatic disease cm liver lesion is new necrotic metastatic lesions affecting the adrenal glands mesenteric lymph nodes the peritoneum and within the left gluteal soft tissues have increased in size short segment of intussuscepted small bowel within the left hemi abdomen which may be incidental but raises suspicion for an underlying metastatic lead point no evidence of small bowel obstruction ct abdomen pelvis w contrast impression small bowel obstruction with transition point at a short segment intussusception within the mid to distal small bowel located in the right lower quadrant in the presence of other intraluminal filling defects within the small bowel as described suspect underlying metastatic lead point diffuse metastatic disease involves a hypodense liver lesion necrotic retroperitoneal and mesenteric adenopathy adrenal glands and peritoneum pertinent 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 discharge labs 55am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 55am blood glucose urean creat na k cl hco3 angap 55am blood calcium phos mg with pmhx metastatic lung cancer s p c1 alimta carboplatin who presented with one week of diffuse crampy abdominal pain and constipation unrelieved with his home pain medications and stool softeners as well as decreased appetite ct a p on admission notable for worsening metastasis of his lung cancer including a new lesion in the liver as well as intussusception with concern for a metastatic lead point evaluated by colorectal surgery and offered surgery given pt goals of care he declined the procedure and ultimately went home with hospice for symptom focused care active issues abdominal pain and intussusception of small intestine constipation pt with one week of diffuse cramping abdominal pain with constipation unrelieved with home pain medications or stool softeners his bowel regimen and pain meds were uptitrated in house ct a p on admission demonstrated worsening metastasis of his lung cancer including new liver lesion worsening adrenal ln soft tissue masses as well as an intussuscepted segment of small bowel with concern for an additional metastatic lead point pt evaluated by colorectal surgery who offered surgical management ultimately pt declined the procedure as it was not within his goals of care he was discharged home with hospice care leukocytosis pt with chronic leukocytosis baseline increased to the s on admission pt without obvious infectious source or infections on admission likely reactive in setting of intussusception was stable at time of discharge back rib pain pt with history of multiple rib fractures which were chronic in nature uptitrated pt home pain regimen as above malnutrition severe pt with very limited po intake xfew months which did not improve during hospitalization despite nursing assistance tpn considered but not within pt goals of care he was provided with nutritional supplements chronic stable issues metastatic lung cancer c1d1 of alimta carboplatin on given severity of progression of disease on in hospital imaging the decision was made to defer further treatment by the patient and his oncologist he will follow up with his oncologist as an outpatient generalized weakness progressive likely due to worsening metastatic lung cancer vs severe malnutrition has previously refused appetite stimulants anemia likely in setting of malignancy no evidence of active bleeding and h h stable throughout cva home dipyridamole aspirin discontinued on discharge transitional issues emergency contact hcp hcp code dnr dni medication changes added fentanyl patch 25mcg q72h bisacodyl 10mg daily docusate 100mg bid polyethylene glycol 17g bid senna 2mg bid increased diazepam 10mg q8h prn 20mg qhs prn anxiety oxycodone q6h prn 20mg q4h prn stopped sildenafil aspirin intussusception ct a p with concern for obstruction at the start of his intussuscepted portion of small bowel likely metastatic lead point had small filling defects in his small bowel on ct a p pt opted for nonoperative management lung cancer pt with worsening metastatic disease was scheduled to receive chemotherapy on deferred in setting of acute illness medications on admission the preadmission medication list is accurate and complete diazepam mg po q8h prn insomnia anxiety dipyridamole aspirin cap po bid folic acid mg po daily ondansetron mg po q8h prn nausea oxycodone immediate release mg po q6h prn pain moderate prochlorperazine mg po q6h prn nausea sildenafil mg po prn intercourse multivitamins tab po daily dexamethasone mg po daily discharge medications bisacodyl mg po pr daily docusate sodium mg po bid fentanyl patch mcg h td q72h rx fentanyl mcg hour apply to skin q72h disp patch refills polyethylene glycol g po bid senna mg po bid diazepam mg po qhs prn insomnia anxiety rx diazepam mg mg by mouth at bedtime disp tablet refills oxycodone immediate release mg po q4h prn pain moderate rx oxycodone mg tablet s by mouth every four hours disp tablet refills dexamethasone mg po daily dipyridamole aspirin cap po bid folic acid mg po daily multivitamins tab po daily ondansetron mg po q8h prn nausea rx ondansetron mg tablet s by mouth every eight hours disp tablet refills prochlorperazine mg po q6h prn nausea discharge disposition home with service facility discharge diagnosis primary intussusception of the small bowel constipation back rib pain secondary lung cancer metastatic discharge condition mental status clear and coherent level of consciousness lethargic but arousable activity status ambulatory independent discharge instructions dear mr it was a pleasure to care for you at the why was i seen in the hospital you were having pain in your belly and severe constipation what happened while i was in the hospital we increased your home pain medications to try to control your pain we provided you with nutrition supplements because you had a low appetite we looked at your belly using a special camera ct scan this showed us two things your lung cancer has spread more widely including a new area that has spread to your liver your pain may have been due to a condition called intussusception in your small bowel you decided not to undergo a surgery for your intussusception due to the risks involved as well as the extent of your cancer you requested that we focus on controlling your pain and symptoms what should i do when i am home you will go home with hospice services who will be able to provide you the supplies and medicines you need to remain comfortable in your home thank you for letting us be involved in your care your care team followup instructions

name unit no admission date discharge date date of birth sex f service plastic allergies peanuts singulair attending chief complaint bilateral popliteal artery entrapment major surgical or invasive procedure bilateral leg popliteal artery releases popliteal neurolysis bilateral myomectomies medial and lateral gastroxnemius muscles bilateral history of present illness is a very active young lady in her who is a high school and college athlete she has been treated in the sports medicine clinic for a number of years for compartment syndromes she has a very short stocky muscular habitus and she has had multiple compartment fasciotomies for exertional compartment syndrome these helped but did not completely solve her stress induced pain completely she subsequently had mris done using the plantar flexion maneuver these showed partial compression of the popliteal artery on both sides worse on the right than the left interestingly on the right side she had a large osteophyte on the posterior aspect of the lateral femoral condyle which is in an area where this compression was seen she was brought to the or today for a popliteal artery decompression this included complete fasciectomy of the posterior aspect of both knees as well as resection of a portion of the origins of the medial and lateral gastrocnemius muscles within the popliteal space she did not have hypertrophied plantaris or popliteus muscles she did not have an extra medial and gastroc on either side past medical history bilateral popliteal entrapment syndrome social history family history noncontributory physical exam at discharge temp po bp hr rr o2 sat o2 delivery ra gen nad a ox3 lying on stretcher heent normocephalic cv rrr r breathing comfortably on room air no wheezing ext wwp dressings in place and are c d i jp drains w ss output bilaterally some diminished sensation bilaterally which is to be expected after this operation able to wiggle toes bilaterally pertinent results n a brief hospital course the patient presented as a same day admission for surgery the patient was taken to the operating room on for bilateral leg popliteal artery releases popliteal neurolysis bilateral myomectomies medial and lateral gastroxnemius muscles bilateral 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 she was also started on a daily 81mg aspirin the patient worked with who determined that discharge to home was appropriate the hospital course was otherwise unremarkable she was given knee immobilizers and crutches to ambulate per protocol at the time of discharge the patient s pain was well controlled with oral medications dressings were clean dry intact and the patient was voiding moving bowels spontaneously the patient is partial weight bearing in her bilateral lower extremities and will be discharged on aspirin 81mg for thrombosis prophylaxis the patient will follow up with dr in weeks per routine a thorough discussion was had with the patient regarding the diagnosis and expected post discharge course including reasons to call the office or return to the hospital and all questions were answered the patient was also given written instructions concerning precautionary instructions and the appropriate follow up care the patient expressed readiness for discharge medications on admission none discharge medications aspirin mg po daily rx aspirin mg tablet s by mouth daily disp tablet refills bisacodyl mg po daily prn constipation first line cefadroxil mg oral bid rx cefadroxil mg capsule s by mouth twice a day disp capsule refills docusate sodium mg po bid gabapentin mg po tid rx gabapentin mg capsule s by mouth three times a day disp capsule refills oxycodone immediate release mg po q4h prn pain moderate rx oxycodone mg tablet s by mouth q4 hours disp tablet refills discharge disposition home discharge diagnosis bilateral popliteal artery entrapment 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 leave your dressings in place until your follow up appointment please do not get your dressings wet sponge bath only please wear your knee immobilizers at all times please use crutches to help you ambulate please record your drain outputs daily 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 facial fractures pneumocephalus major surgical or invasive procedure none history of present illness patient is a year old gentleman who was playing in a family softball game when he was struck in the face by a line drive of a softball he was taken to an osh where evaluation showed multiple facial fractures and a trace amount of pneumocephalus he was given ancef and a tetanus shot and he was subsequently transferred to for further monitoring and care past medical history afib social history family history nc physical exam gen wd wn comfortable nad heent left sided facial swelling pupils eoms intact wothout nystagmus neck supple lungs cta bilaterally cardiac rrr s1 s2 abd soft nt bs extrem warm and well perfused neuro mental status awake and alert cooperative with exam normal affect orientation oriented to person place and date language speech fluent with good comprehension and repetition naming intact no dysarthria or paraphasic errors cranial nerves i not tested ii pupils equally round and reactive to light to 1mm bilaterally visual fields are grossly full to confrontation iii iv vi extraocular movements intact bilaterally without nystagmus v vii facial strength and sensation intact and symmetric viii hearing intact to voice ix x palatal elevation symmetrical xi sternocleidomastoid and trapezius normal bilaterally xii tongue midline without fasciculations motor normal bulk and tone bilaterally no abnormal movements tremors strength full power throughout no pronator drift sensation intact to light touch propioception pinprick and vibration bilaterally toes downgoing bilaterally coordination normal on finger nose finger pertinent results ct no hemorrhage trace pneumocephalus right frontal lobe comminuted fracture of the left frontal bone anterior wall of the left frontal sinus fractures extend in to the left ethmoid air cells fracture extends across the midline into the anterior wall of the right frontal sinus there is depression of fragments there are posterior frontal sinus wall fractures there is a comminuted fracture of the left orbital roof there is left orbital emphysema there is a minimally displaced left lamina papyracea fracture there is mild widening of the left zygomaticofrontal suture there are air fluid levels in the frontal and maxillary sinuses and partial opacification of the ethmoid sinuses brief hospital course mr was admitted to the neurosurgery service for observation for csf leak he was seen and evaluated by plastic surgery for complex bilateral frontal sinus fractures with depressed components and left orbital roof fracture they recommend sinus precautions augmentin x7 days and follow up within a week for possible delayed fixation of fractures he was seen and evaluated by ophthalmology who did a dilated bedside exam they recommend follow up with ophthalmology a retinal specialist for retinal commotio within week for a formal dilated fundoscopic exam during his admission mr remained neurologically intact without any signs of csf rhinorrhea at the time of discharge he was tolerating a regular diet ambulating without difficulty afebrile with stable vital signs the patient will discharge to home and arrange for outpatient follow up with ophthalmology and plastic surgery close to his home in medications on admission aspirin mg discharge medications acetaminophen mg po q6h prn fever pain amoxicillin clavulanic acid mg po q12h duration days rx amoxicillin pot clavulanate mg mg tablet s by mouth twice a day disp tablet refills docusate sodium mg po bid oxycodone immediate release mg po q4h prn pain moderate rx oxycodone mg tablet s by mouth every hours disp tablet refills discharge disposition home discharge diagnosis complex depressed bifrontal sinus fractures involving both the anterior and posterior tables left orbital roof fracture retinal commotio discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions activity sinus precautions no straws do not blow your nose sneeze with open mouth do not smoke cigarettes pipes or cigars avoid swimming and strenuous exercise for one week ice to left eyelid x hours seek emergency eye evaluation for any change in vision sudden onset of shower of new floaters persistent flashes of light or curtain over vision we recommend that you avoid heavy lifting running climbing or other strenuous exercise until your follow up appointment no driving while taking any narcotic or sedating medication you should avoid contact sports for months medications you may use acetaminophen tylenol for minor discomfort if you are not otherwise restricted from taking this medication what you experience with traumatic brain injury you may have difficulty paying attention concentrating and remembering new information emotional and or behavioral difficulties are common feeling more tired restlessness irritability and mood swings are also common constipation is common be sure to drink plenty of fluids and eat a high fiber diet if you are taking narcotics prescription pain medications try an over the counter stool softener headaches headache is one of the most common symptoms after traumatic brain injury headaches can be long lasting most headaches are not dangerous but you should call your doctor if the headache gets worse develop arm or leg weakness increased sleepiness and or have nausea or vomiting with a headache mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor there are other things that can be done to help with your headaches avoid caffeine get enough sleep daily exercise relaxation meditation massage acupuncture heat or ice packs more information about brain injuries you were given information about headaches after tbi and the impact that tbi can have on your family if you would like to read more about other topics such as sleeping driving cognitive problems emotional problems fatigue seizures return to school depression balance or and sexuality after tbi please ask our staff for this information or visit followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies cipro attending chief complaint consideration of cath major surgical or invasive procedure none history of present illness with cad cabg des x2 unclear anatomy htn hld dm who presented to bi p with chest pain found to have nstemi tropi and st depressions in anterolateral leads st elevation in avr transferred to for consideration of cath initially presented to bi p on with syncope negative trauma evaluation but with diffuse st depressions on ecg and troponin i rise from to to peak of he was asymptomatic at that time tte at that time showed ef50 but akinetic infero lateral wall and basal to mid wall he received medical management with asa iv heparin plavix beta blocker and was discharged on discharged from bi p however this am he developed crushing r chest pain his anginal equivalent and thought he was going to die bibems to bi p there trop i and ecg again showed diffuse st depressions and st elevation in avr cxr with pulmory edema edema received asa324mg ntg paste started on heparin gtt labs there also noted mild stable anemia hb mid high 9s with negative fobt chem panel with cr baseline appears cardiology evaluation there felt to have l main lesion requiring emergent transfer for stenting pre transfer vss and ra at pt reports currently is chest pain free no abd pain nausea vomiting diaphoresis fever chills diarrhea urinary c o in the ed initial vs ra ekg nsr with rbbb lafb st depressions in anterolateral leads and st elevation in avr labs notable for tropt ckmb cr bnp mg studies notable for cxr overall improvement in central pulmonary edema now mild moderate no focal consolidation consults cardiology patient was given iv heparin iv mg clopidogrel mg vitals on transfer ra on the cardiology service he endorses the history above he reports the chest pain has resolved and he is not experiencing any pain or pressure currently review of systems positive per hpi cardiac review of systems is notable for absence of chest pain dyspnea on exertion paroxysmal nocturnal dyspnea orthopnea ankle edema palpitations syncope or presyncope on further review of systems denies fevers or chills denies any prior history of stroke tia deep venous thrombosis pulmonary embolism bleeding at the time of surgery myalgias joint pains cough hemoptysis black stools or red stools denies exertional buttock or calf pain all of the other review of systems were negative past medical history cardiac risk factors diabetes hypertension dyslipidemia cardiac history cad remote cabg in at reportedly with des x2 unclear anatomy other past medical history gerd social history family history nc physical exam admission exam vs 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 no jvd cardiac pmi located in intercostal space midclavicular line regular rate and rhythm normal s1 s2 no murmurs rubs or gallops no thrills or lifts lungs no chest wall deformities or tenderness respiration is unlabored with no accessory muscle use no crackles wheezes or rhonchi abdomen soft non tender non distended no hepatomegaly no splenomegaly extremities warm well perfused no clubbing cyanosis or peripheral edema skin no significant skin lesions or rashes pulses distal pulses palpable and symmetric discharge exam hr data last updated temp tm bp hr rr o2 sat o2 delivery ra hr data last updated 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 no jvd cardiac pmi located in intercostal space midclavicular line regular rate and rhythm normal s1 s2 no murmurs rubs or gallops no thrills or lifts lungs no chest wall deformities or tenderness respiration is unlabored with no accessory muscle use no crackles wheezes or rhonchi abdomen soft non tender non distended no hepatomegaly no splenomegaly extremities warm well perfused no clubbing cyanosis or peripheral edema skin no significant skin lesions or rashes pulses distal pulses palpable and symmetric pertinent results admision 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 08pm blood ptt 00pm blood glucose urean creat na k cl hco3 angap 39pm blood alt ast alkphos totbili 08pm blood ck mb mb indx 00pm blood calcium phos mg 39pm blood hdl chol hd 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 alt ast alkphos 40am blood calcium phos mg imaging tte conclusion the left atrial volume index is normal there is normal left ventricular wall thickness with a normal cavity size overall left ventricular systolic function is moderately to severely depressed secondary to hypokinesis of the inferior free wall and akinesis with focal dyskinesis of the posterior and lateral walls the visually estimated left ventricular ejection fraction is left ventricular cardiac index is depressed less than l min m2 there is no resting left ventricular outflow tract gradient normal right ventricular cavity size with depressed free wall motion tricuspid annular plane systolic excursion tapse is depressed the aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender the aortic arch diameter is normal with a normal descending aorta diameter the aortic valve leaflets are mildly thickened there is no aortic valve stenosis there is trace aortic regurgitation the mitral valve leaflets are mildly thickened with no mitral valve prolapse there is moderate mitral regurgitation the pulmonic valve leaflets are normal the tricuspid valve leaflets appear structurally normal there is mild tricuspid regurgitation there is moderate pulmonary artery systolic hypertension there is no pericardial effusion impression inferoposterolateral myocardial infarct cxr findings in comparison to the prior radiograph diffuse bilateral reticular opacities and septal thickening are improved compared to the prior study there is mild moderate persistent central pulmonary edema slightly worse on the left there is bronchovascular cuffing likely trace left pleural effusion no pneumothorax no large focal consolidation the heart is mildly enlarged the mediastinum is stable in size postsurgical changes after median sternotomy and cabg are demonstrated impression overall improvement in central pulmonary edema now mild moderate no focal consolidation brief hospital course transitional issues discharge weight kg lb discharge cr discharge diuretic none medication changes new nitroglycerin sl mg atorvastatin mg daily stopped nifedipine 30mg daily simvastatin 80mg daily changed increased metoprolol succinate xl from 5mg daily to mg daily transitional issues did not start due to elevated cr and soft blood pressures can be considered as outpatient for pcp a1c will require continued monitoring as outpatient please recheck sodium and creatinine within week to ensure not hyponatremic and no likely due to decreased po intake from hospital food continue to assess goals of care and and need for rehab code status dnr dni contact name of health care proxy number summary with cad cabg des x2 unclear anatomy htn hld dm who presented to bi p with chest pain found to have nstemi tropi and st depressions in anterolateral leads st elevation in avr transferred to for consideration of cath now with plan for medical management coronaries prior cabg 2xdes unknown coronary anatomy pump ef rhythm nsr active issues type i nstemi history of cad and remote cabg and 2xdes he doesn t remember the details initial presentation on to for syncope with rising troponin diffuse st depressions with st elevation in avr concerning for diffuse ischemia such as l main disease he was medically managed with asa heparin gtt bb plavix and discharged on his peak troponin i was he then represented on for chest pain and had troponin i of epressions as before he was started on heparin gtt asa mg and transferred to for consideration of cath at he reported being chest pain free tropt with mb down trending to tte showed ef with inferoposterolateral myocardial infarct event was thought to be hours out and given his age and prior cabg risks benefits were discussed with interventional attending and cardiology fellow who recommended medical management and reassessment if he were to develop chest pain discussed with patient and he would rather avoid cath if possible we discussed that if he were to have worsening chest pain we may pursue this option and could reverse his dnr dni he and his family agree with this noninvasive plan plan to optimize medical management he was treated with asa 81mg plavix 75mg atorvastatin 80mg metoprolol restarted his home isosorbide mononitrate 30mg daily initally treated with iv heparin gtt acei was not started due to his cr can be considered in outpatient if cr improves stopped nifedipine 30mg daily as he his metoprolol was increased dm a1c at bi p restarted on home glipizide on discharge medications on admission the preadmission medication list is accurate and complete metoprolol succinate xl mg po daily aspirin mg po daily isosorbide mononitrate extended release mg po daily nifedipine extended release mg po daily simvastatin mg po qpm pantoprazole mg po q12h glipizide xl mg po daily clopidogrel mg po daily paroxetine mg po daily discharge medications atorvastatin mg po qpm rx atorvastatin mg tablet s by mouth at bedtime disp tablet refills nitroglycerin sl mg sl q5min prn chest pain take tab every mins as needed for chest pain if pain doesn t resolve after tablets call rx nitroglycerin mg tablet s sublingually every mins disp tablet refills metoprolol succinate xl mg po daily rx metoprolol succinate mg tablet s by mouth once a day disp tablet refills aspirin mg po daily rx aspirin mg tablet s by mouth once a day disp tablet refills clopidogrel mg po daily rx clopidogrel mg tablet s by mouth once a day disp tablet refills glipizide xl mg po daily rx glipizide glucotrol xl mg tablet s by mouth once a day disp tablet refills isosorbide mononitrate extended release mg po daily rx isosorbide mononitrate mg tablet s by mouth once a day disp tablet refills pantoprazole mg po q12h rx pantoprazole mg tablet s by mouth twice a day disp tablet refills paroxetine mg po daily rx paroxetine hcl mg tablet s by mouth once a day disp tablet refills discharge disposition home with service facility discharge diagnosis primary diagnosis type i nstemi secondary diagnosis type diabetes mellitus hypertension diabetes mellitus discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions discharge instructions dear mr it was a pleasure taking care of you at the thank you for allowing us to be involved in your care we wish you all the best your healthcare team why was i in the hospital you were admitted because you had a heart attack what happened in the hospital you were found to have some damage to your heart together with you we decided to avoid looking inside the arteries of your heart cardiac catherization we gave you medications to treat your heart instead what should i do when i go home be sure to take all your medications and attend all of your appointments listed below followup instructions

name unit no admission date discharge date date of birth sex f service surgery allergies cipro flagyl dilaudid morphine demerol darvocet n attending chief complaint diverticulitis major surgical or invasive procedure robotic partial left colectomy with takedown of splenic flexure stapled coloproctostomy and firefly assessment of vascular inflow history of present illness first episode divertiulitis requiring hospitalization prior and again recently hospitalized at with complicated diverticulitis preceded by llq pain attacks and pressure culminating in hospitalization and iv antibiotics with ct scan demonstrating 2cm abscess in the sigmoid colon treated with iv antibiotics subsequently transitioned to bid augmentin which she has been taking without interruption reportedly normal screening colonoscopy denies personal or family history of ibd notes questionable history of colon cancer in maternal relative diagnosed at of age currently denies fevers chills nausea or vomiting notes normal bowel function and flatus but on a restricted diet since last seen with planned laparoscopic assisted robotic sigmoid resection for subsequently rescheduled to at time of consultation pt afvss with wbc focal llq tenderness without peritoneal signs and uncomplicated diverticulitis in the descending colon past medical history hypercholesterolemia social history family history negative for inflammatory bowel disease physical exam gen awake and alert cv rrr lungs ctab abd soft nontender nondistended laparoscopic sites clean dry and intact pertinent results 25am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 20am blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 25am blood glucose urean creat na k cl hco3 angap 25am blood calcium phos mg brief hospital course presented to pre op holding at on for a lap robotic sigmoid colectomy she tolerated the procedure well without complications please see operative note for further details after a brief and uneventful stay in the pacu the patient was transferred to the floor for further post operative management foley was taken out on and she was able to void without difficulty she was advanced to a regular diet as well her drain was removed on without complication neuro the patient received oxycodone with good effect and adequate pain control 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 post operatively the patient was made npo with iv fluids diet was advanced when appropriate which was well tolerated patient s intake and output were closely monitored and iv fluid was adjusted when necessary electrolytes were routinely followed and repleted when necessary id the patient s white blood count and fever curves were closely watched for signs of infection endocrine the patient s blood sugar was monitored throughout the stay hematology the patient s complete blood count was examined routinely for signs of bleeding and anemia prophylaxis the patient received subcutaneous heparin during this stay was encouraged to get up and ambulate as early as possible on the patient was discharged to home at discharge she was tolerating a regular diet passing flatus voiding and ambulating independently she will follow up in the clinic in weeks this information was communicated to the patient directly prior to discharge include in brief hospital course for every patient and check of boxes that apply post surgical complications during inpatient admission post operative ileus resolving w o ngt post operative ileus requiring management with ngt uti wound infection anastomotic leak staple line bleed congestive heart failure arf acute urinary retention failure to void after foley d c d acute urinary retention requiring discharge with foley catheter dvt pneumonia abscess x none social issues causing a delay in discharge delay in organization of services difficulty finding appropriate rehabilitation hospital disposition lack of insurance coverage for services lack of insurance coverage for prescribed medications family not agreeable to discharge plan patient knowledge deficit related to ileostomy delaying discharge x no social factors contributing in delay of discharge medications on admission the preadmission medication list is accurate and complete esomeprazole magnesium mg oral daily simvastatin mg po qpm thyroid mg po daily discharge medications oxycodone immediate release mg po q4h prn pain do not drink alcohol or drive a car while taking this medication rx oxycodone mg tablet s by mouth every four hours disp tablet refills esomeprazole magnesium mg oral daily simvastatin mg po qpm thyroid mg po daily home med it is ok to restart probiotics acetaminophen mg po q6h prn pain nystatin oral suspension ml po qid prn thrush rx nystatin unit ml ml by mouth times daily refills discharge disposition home discharge diagnosis acute on chronic diverticulitis involving the sigmoid colon and descending colon discharge condition mental status clear and coherent activity status ambulatory independent activity status ambulatory independent level of consciousness alert and interactive discharge instructions you were admitted to the hospital after a laparoscopic colectomy for surgical management of your diverticulitis you have recovered from this procedure well and you are now ready to return home samples from your colon were taken and this tissue has been sent to the pathology department for analysis you will receive these pathology results at your follow up appointment if there is an urgent need for the surgeon to contact you regarding these results they will contact you before this time you have tolerated a regular diet are passing gas and your pain is controlled with pain medications by mouth you may return home to finish your recovery please monitor your bowel function closely you may or may not have had a bowel movement prior to your discharge which is acceptable however it is important that you have a bowel movement in the next days after anesthesia it is not uncommon for patient s to have some decrease in bowel function but you should not have prolonged constipation some loose stool and passing of small amounts of dark old appearing blood are expected however if you notice that you are passing bright red blood with bowel movements or having loose stool without improvement please call the office or go to the emergency room if the symptoms are severe if you are taking narcotic pain medications there is a risk that you will have some constipation please take an over the counter stool softener such as colace and if the symptoms do not improve call the office if you have any of the following symptoms please call the office for advice or go to the emergency room if severe increasing abdominal distension increasing abdominal pain nausea vomiting inability to tolerate food or liquids prolonged loose stool or extended constipation you have laparoscopic surgical incisions on your abdomen which are closed with internal sutures and a skin glue called dermabond these are healing well however it is important that you monitor these areas for signs and symptoms of infection including increasing redness of the incision lines white green yellow malodorous drainage increased pain at the incision increased warmth of the skin at the incision or swelling of the area please call the office if you develop any of these symptoms or a fever you may go to the emergency room if your symptoms are severe you may shower pat the incisions dry with a towel do not rub the small incisions may be left open to the air if closed with steri strips little white adhesive strips instead of dermabond these will fall off over time please do not remove them please no baths or swimming for weeks after surgery unless told otherwise by your surgical team you will be prescribed narcotic pain medication oxycodone this medication should be taken when you have pain and as needed as written on the bottle this is not a standing medication you should continue to take tylenol for pain around the clock and you can also take advil please do not take more than 3000mg of tylenol in hours do not drink alcohol while taking narcotic pain medication or tylenol please do not drive a car while taking narcotic pain medication no heavy lifting greater than lbs for until your first post operative visit after surgery please no strenuous activity until this time unless instructed otherwise by dr dr thank you for allowing us to participate in your care our hope is that you will have a quick return to your life and usual activities good luck followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies no known allergies adverse drug reactions attending chief complaint nausea vomiting major surgical or invasive procedure none history of present illness hx bicornuate uterus pid otherwise healthy who presents with nausea and vomiting her most recent symptoms started today but she had similar symptoms earlier this month as below today n v awoke her from sleep she has had multiple episodes of nbnb emesis no abdominal pain diarrhea constipation has very mild generalized discomfort similar symptoms weeks ago recently moved here from for her work one month ago was about to move out when she developed nausea vomiting fatigue other family members had this symptom this resolved then about two weeks ago she developed a few episodes of severe abrupt onset nbnb emesis that felt better after vomiting there has been minimal abdominal pain no diarrhea no fevers that she s aware of a few days ago she went to urgent care at in where she felt that they were convinced i was pregnant a urine pregnancy test was reportedly negative she is sexually active with her boyfriend they are monogamous to her knowledge she takes ocps and has not missed any doses recently at they felt her nausea vomiting were due to anxiety symptoms and prescribed prn zofran for this which she has been taking with some relief in the past she redeveloped n v and was having chills and sweats at home of note she denies dysuria and dyspareunia she notes this is most similar to an episode of pelvic infection she had at a hospital in about ago during that admission she recalls having tte they found a mild arrhythmia but nothing serious ctap nothing abnormal and a pelvic ultrasound showed bicornuate uterus in the ed initial vital signs were ra exam notable for benign observed sample of emesis no gross blood labs were notable for wbc otherwise unremarkable imaging none the patient was given ivf lorazepam ceftriaxone consults none diagnosed with pyelonephritis and admitted to medicine given inability to tolerate po vitals prior to transfer were ra on the floor patient recounts the hx above she denies symptoms other than mild n v lower abdominal discomfort worst just l of the umbilicus denies dysuria dyspareunia or purulent cervical discharge has had chills at home no other symptoms denies chest pain dyspnea unusual foreign travel unusual food exposures review of systems per hpi past medical history bicornuate uterus hx pelvic infection at a hx mild arrhythmia social history family history mother sister with uc father d in of gastric cancer physical exam exam on admission vitals ra genl well appearing pleasant nad heent no icterus perrla mmm no op lesions neck no lad cor rrr sem throughout precordium pulm no incr wob ctab abd soft minimal ttp just l of the umbilicus at around o clock gyn pelvic exam performed with rn chaperone normal external female genitalia without any lesions speculum small amount of blood in vaginal vault cervix could not be visualized no obvious purulence bimanual cervix is r sided and posteriorly facing no cmt neuro aox3 skin no obvious lesions or rashes of the torso ues exam on discharge vitals ra genl well appearing pleasant nad neck no lad cor rrr no murmurs pulm no incr wob ctab abd soft minimal ttp just l of the umbilicus at around o clock neuro aox3 skin no obvious lesions or rashes of the torso ues results labs on admission 35pm 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 glucose urean creat na k cl hco3 angap 35pm blood alt ast alkphos totbili 35pm blood lipase 40am blood calcium phos mg 35pm blood albumin 31pm blood lactate labs on discharge 40am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 40am blood glucose urean creat na k cl hco3 angap microbiology gc ct negative urine culture e coli blood cultures x2 ngtd imaging none brief hospital course no sign pmhx presenting with n v admitted for iv abx and observation given inability to tolerate po nausea vomiting abdominal discomfort patient presented with abdominal pain of unclear etiology she was found to have leukocytosis which resolved overnight and was mostly likely related to the patient s vomiting she had no fevers she was found to have a uti and was started on ceftriaxone exam was negative for cva tenderness making pyelonephritis unlikely a pelvic exam showed no cervical motion tenderness and gc ct testing was negative she has a family history of gastric cancer but this was felt to be very unlikely given patient s age lack of risk factors and that she had no other symptoms concerning for malignancy she also has a family history of ulcerative colitis but patient did not report any changes in bowel movements and no diarrhea reported no heartburn given frequent use of marijuana cyclic vomiting syndrome was considered as a possible diagnosis other possible causes are the oral contraceptive pill which she started several weeks ago and anxiety after receiving ivf overnight the patient was able to tolerate pos she was discharged home with plan to establish with a pcp to further evaluate causes of her nausea urinary tract infection as above patient had no urinary symptoms but was found to have a positive u a with a culture growing e coli she was covered on ceftriaxone and sent home with bactrim to complete a day course transitional issues consider changing ocp to iud for better compliance issues and possibility of symptoms being attributed to pseudomotor cerebri would like hip pain chronic to be worked up as an outpatient consider pelvic ultrasound to work up symptoms if persisting complete uti course of antibiotics with bactrim last day consider empiric ppi treatment if symptoms persist contact mother code status presumed full medications on admission none discharge medications sulfameth trimethoprim ds tab po bid rx sulfamethoxazole trimethoprim bactrim ds mg mg tablet s by mouth every hours disp tablet refills ondansetron mg po q8h prn nausea rx ondansetron hcl mg tablet s by mouth every hours disp tablet refills discharge disposition home discharge diagnosis primary nausea vomitting 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 having you here at the you were admitted here after you were found to have nausea and vomiting your pregnancy test was negative you were found to have urine which showed signs of an infection you will need to take one additional day of antibiotics to complete treatment for this last day we think your symptoms could be due to consumption of marijuana we feel decreasing intake of this will help please follow up with your outpatient appointments below we wish you the very best your medical team followup instructions

name unit no admission date discharge date date of birth sex m service surgery allergies no known allergies adverse drug reactions attending chief complaint right chest wall pain major surgical or invasive procedure s p bilateral chest tube placement due to bilateral pneumothorax right chest tube placed taken out on left chest tube placed removed bilateral internal iliac gel foam embolization history of present illness year old male s p pedestrian struck on right side at approximately 7pm on injury burden as listed below per report the car was traveling at loc right chest wall crepitance tension pnemothorax s p needle decompression and chest tube placement in ed pelvic bleed with active extravasation on ct he received 1u prbc in ed orthopaedic surgery was consulted for right sided sacral and pubic ramus fractures he also have a right distal clavicle fracture noted on cxr s p bilateral chest tube placement due to bilateral pneumothorax right chest tube placed taken out on left chest tube placed not yet removed bilateral internal iliac gel foam embolization patient has been ambulating with here and will be d c to a rehab hospital to continue management the patients pain has improved and he is tolerating a regular diet past medical history no past medical history social history family history no significant family medical history physical exam physical examination upon admission temp hr bp resp o sat normal constitutional no acute distress heent left forehead abrasion pupils equal round and reactive to light airway intact chest equal breath sounds bilaterally cardiovascular regular rate and rhythm abdominal nontender soft extr back right lateral chest wall has crepitus to palpation pelvis is stable right lateral proximal femur ttp skin abrasions on left forehead right knee right lateral malleolus left ulnar hand left lateral ankle neuro speech fluent ble strength intact psych normal mentation no petechiae physical examination upon discharge general nad cv ns1 s2 no murmurs lungs clear abdomen soft non tender hypoactive bs ext scattered ecchymosis upper and lower ext right groin site clean and dry mentation alert and oriented x speech clear pertinent results 39am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 02am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 35pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 39am blood plt 00am blood ptt 39am blood glucose urean creat na k cl hco3 angap 45pm blood ld ldh 39am blood calcium phos mg 31am blood lactate diagnosis assessment and recommendations mr has a new diagnosis of an anti k antibody the is a member of the kell blood group system anti k is clinically significant and can cause hemolytic transfusion reactions in the future mr should receive negative products for all red blood cell transfusions approximately of abo compatible blood will be negative a wallet card and a letter stating the above will be sent to the patient cat scan of the head no acute intracranial process right parietal subgaleal hematoma without underlying skull fracture moderate global cerebral atrophy cat scan of the c spine no fracture or mal alignment in the cervical spine multilevel degenerative disease probable fracture involving the right transverse process of t1 subcutaneous emphysema in the neck right greater than left tiny apical pneumothorax left greater than right better assessed on concomitant ct torso examination cat scan of the chest scattered right pulmonary contusion small right and left pneumothorax small bilateral hemothorax right chest tube in place large pelvic hematoma with active bleeding right pelvic fractures involving right sacral ala right pubic bone injury to the urinary bladder and urethra difficult to exclude consider ct cystogram and retrograde urethrogram acute fractures involving ribs detailed above r l left lumbar transverse processes right distal clavicle abdomen single portable view of the pelvis provided a contrast within the urinary bladder is noted the urinary bladder has an abnormal configuration likely due to mass effect from adjacent hematoma better seen on ct no definite signs of extravasation fractures of the right superior and inferior pubic ramus are again seen bilateral hip degenerative disease is of noted x ray of the clavicle minimally displaced distal clavicle fracture is again noted there are second and third rib fractures more completely visualized and torso ct from day earlier subcutaneous emphysema is again noted superior subluxation of the humeral head is compatible with a chronic rotator cuff tear there is no gleno humeral joint dislocation ac and gleno humeral joint osteoarthritis chest x ray the previously small left apical pneumothorax is increased small right apical pneumothorax is mildly improved and previously mild left basal atelectasis increased since chest x ray there is a stable moderate left apical pneumothorax with a loculated basilar hydro pneumothorax the right apical pneumothorax is no longer appreciated linear opacity at the right base likely reflects subsegmental atelectasis there is persistent but resolving subcutaneous emphysema within the right lateral chest wall soft tissues no pulmonary edema overall cardiac and mediastinal contours are stable subacute fractures of at least the right third fifth and sixth posterolateral ribs better appreciated on the ct dated clips in the right upper quadrant consistent with prior cholecystectomy chest x ray in comparison with the earlier study of this date the left chest tube has been removed the left apical pneumothorax has not increased brief hospital course year old gentleman admitted to the hospital after being struck by a car he had no recollection of the accident upon admission the patient was hypotensive and noted to have right chest wall crepitus and reported to have a tension pneumothorax he underwent needle decompression and subsequent placement of a chest tube imaging studies showed multiple fractures including bilateral rib fractures bilateral lumbar transverse process fractures right pulmonary contusion bilateral pneumonthorax right clavicle fracture pelvic bleed with active extravasation and bladder perforation because of the patient s hypotension he received unit prbc in the ew after imaging studies were completed the patient was admitted to the intensive care unit the patient received an additional unit of blood in the trauma intensive care unit his cervical spine was stabilized in the collar because of the active bleeding in the pelvis the patient was taken to for gel foam embolization of the left internal iliac artery anterior division and the right internal iliac artery orthopedic surgery was consulted for right sided sacral and pubic ramus fractures and a right distal clavicle fracture noted on cxr the patient denied parethesia or weakness of the distal right upper extremity the pelvic fracture was treated in a closed manner with no manipulation and the the patient was allowed to bear weight after the patient s hematocrit stabilized he was transferred to the surgical floor upon admission to the surgical floor the patient resumed a regular diet imaging studies showed no spinal fractures and the cervical collar was removed after a non tender physical examination of the neck on hd the right chest tube was placed to water seal and later removed the patient s oxygen saturation was monitored and the patient was instructed in the use of the incentive spirometer despite these measures the patient continued to have an oxygen requirement and on chest x ray was reported to have a left basilar hydro pneumothorax and a chest tube was placed with the removal of 400cc fluid after imaging showed resolution of the fluid collection the chest tube was removed the patient s oxygenation saturation remained stable and he was weaned off the oxygen in preparation for discharge the patient was evaluated by physical and occupational therapy and cleared for discharge home with the services including physical therapy the patient s vital signs remained stable and he was afebrile his hematocrit stabilized at his pain was controlled with oral analgesia and he was voiding without difficulty the patient was discharged home on in stable condition an appointment for follow up was made with the acute care and orthopedic service prior to discharge the patient received instruction in lovenox injections recommended by the orthopedic service course to be determined by the orthopedic service medications on admission baby aspirin discharge medications oxycodone immediate release mg po q4h prn pain rx oxycodone mg tablet s by mouth every four hours disp tablet refills senna mg po bid prn constipation docusate sodium mg po bid rx docusate sodium mg tablet s by mouth twice a day disp tablet refills acetaminophen mg po q6h prn pain aspirin mg po daily enoxaparin sodium mg sc daily start today first dose next routine administration time rx enoxaparin mg ml mg once a day disp syringe refills discharge disposition home with service facility discharge diagnosis right pulmonary contusion ptx left ptx right sacral ala pubic bone fracture with hematoma right clavicle fracture bilateral rib fractures right left left lumbar tp fracture right t1 tp fracture right subgaleal hematoma 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 year old male struck by car with positive loss of consciousness bilateral rib fractures right pneumothorax pulmonary contusion s p chest tube bilaterally your lungs have re expanded and the chest tubes were removed you also sustained a sacral pelvic fractures with a pelvic hematoma because you had bleeding in your pelvis you underwent embolization you are being discharged with the following instruction because you sustained rib fractures please follow these instructions your injury caused bilateral rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain you should take your pain medication as directed to stay ahead of the pain otherwise you won t be able to take deep breaths if the pain medication is too sedating take half the dose and notify your physician pneumonia is a complication of rib fractures in order to decrease your risk you must use your incentive spirometer times every hour while awake this will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs you will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing symptomatic relief with ice packs or heating pads for short periods may ease the pain narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible do not smoke if your doctor allows non steroidal antiinflammatory drugs are very effective in controlling pain ie ibuprofen motrin advil aleve naprosyn but they have their own set of side effects so make sure your doctor approves return to the emergency room right away for any acute shortness of breath increased pain or crackling sensation around your ribs crepitus general care instructions 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 followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies metformin attending chief complaint vt storm major surgical or invasive procedure endotracheal intubation at osh prior to admission history of present illness w cad s p remote 2v cabg and pci vt and vf s p aicd medtronix bi v hfref ef insulin dependent diabetes ckd b l cr hypothyroidism and etoh use disorder who presents as a transfer from for recurrent vt shocked times following an admission there on for a syncopal episode in the setting of vtach the patient had a syncopal episode at home and was found to be in slow vt apparently denied chest pain and aicd did not get triggered cpr was started and the patient was defibrillated in the field upon arrival in the ed he had recurrent episodes of vt and continued to be syncopal in spite of multiple shocks amiodarone 300mg and iv lidocaine he continued to have multiple episodes of vt he was also found to be hypoglycemic w fsbg emts did report that he did smell of etoh when they picked uim up but the patient denied drinking any significant amounts of etoh in the ed labs were notable for trop wnl cbc and chem10 wnl except for hypokalemia and acidemia k was repleted and pt received bicarb patient was cathed reported to have no intervenable lesion no ischemic etiology of vt was found lcx patent w stent lima to lad patent known occluded lad rca svg to rca scg to om patent unchanged from prior he had his aicd interrogated and settings were changed to defibrillate at lower hr patient continued to have multiples episodes of mmvt many w hrs 150s 160s accompanied by hypotension and was intubated to control airway for sedation iso receiving multiple shocks he was treated with amio bolus gtt lidocaine bolus gtt procainamide bolus gtt also required levophed drip for hypotension which was weaned also received iv metop bolus once normotensive repeat tte was obtained which showed ef worse from prior of note during his hospitalization he was noted to be tremulous and was diagnosed with mild etoh withdrawal was treated with librium ativan with improvement at time of transfer he has been shocked times he is still intubated on propofol and continued on the procainamide gtt amio gtt after load metoprolol 50mg tid he was also volume up w net on and received lasix iv 40mg and spironolactone 5mg this am he is still receiving ativan prn for etoh withdrawal tremulousness per ems his aicd is not capturing the vt last time he was shocked at on at which time the procainamide amio were started review of systems positive per hpi cardiac review of systems is notable for absence of chest pain dyspnea on exertion paroxysmal nocturnal dyspnea orthopnea ankle edema palpitations syncope or presyncope on further review of systems denies fevers or chills denies any prior history of stroke tia deep venous thrombosis pulmonary embolism bleeding at the time of surgery myalgias joint pains cough hemoptysis black stools or red stools denies exertional buttock or calf pain all of the other review of systems were negative past medical history past medical history cardiac risk factors insulin dependent diabetes hypertension dyslipidemia cardiac history cad w cabg w subsequent stents hfref ef cardiac arrest w vt and vf s p aicd other past medical history chronic kidney disease b l cr hypothyroidism social history family history not obtained physical exam admission physical examination vs bp hr rr o2 sat on vent settings tv peep r fio2 general well developed well nourished in nad intubated heent normocephalic atraumatic sclera anicteric perrl eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthelasma neck supple jvp not elevated cardiac pmi located in intercostal space midclavicular line regular rate and rhythm normal s1 s2 no murmurs rubs or gallops lungs no chest wall deformities or tenderness respiration is unlabored with no accessory muscle use no crackles wheezes or rhonchi abdomen soft non tender non distended no hepatomegaly no splenomegaly extremities warm well perfused no clubbing cyanosis or peripheral edema skin no significant skin lesions or rashes pulses dp pulses palpable bilaterally discharge physical examination vs ra i os 24hr 24hr 8hr weight 4kg new dry weight general well developed well nourished in nad heent normocephalic atraumatic sclera anicteric perrl eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthelasma neck supple jvp not elevated cardiac pmi located in intercostal space midclavicular line regular rate and rhythm normal s1 s2 no murmurs rubs or gallops lungs no chest wall deformities or tenderness respiration is unlabored with no accessory muscle use no crackles wheezes or rhonchi abdomen soft non tender non distended no hepatomegaly no splenomegaly extremities warm well perfused no clubbing cyanosis or peripheral edema skin ecchymosis noted on upper extremities pulses dp pulses palpable bilaterally mental status a o x3 pertinent results admission labs 34pm type art tidal vol o2 po2 pco2 ph total co2 base xs 34pm lactate 50pm glucose urea n creat sodium potassium chloride total co2 anion gap 50pm estgfr using this 50pm alt sgpt ast sgot alk phos tot bili 50pm ck mb ctropnt 50pm calcium phosphate magnesium 50pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 50pm plt count 50pm ptt microbiology urine cx negative urine cx negative urine cx negative blood cx x2 negative blood cx x2 negative blood cx x2 negative c difficile dna amplification assay final negative for toxigenic c difficile by the cepheid nucleic acid amplification assay mrsa screen final no mrsa isolated c difficile dna amplification assay pending imaging cxr portable mild vascular congestion has improved mild to moderate cardiomegaly is stable pacer leads are in standard position et tube is in standard position right ij catheter tip is in the mid to lower svc ng tube tip is out of view below the diaphragm right lower lobe opacities are a combination of small effusion and adjacent atelectasis there is no evident pneumothorax nchct findings there is no evidence of infarction hemorrhage edema or mass the ventricles and sulci are normal in size and configuration there are atherosclerotic calcifications in the bilateral cavernous carotids and vertebral arteries there is no evidence of fracture there is mucosal thickening in the ethmoid air cells the visualized portion of the remainder of the paranasal sinuses mastoid air cells and middle ear cavities are clear patient is status post bilateral lens replacement the visualized portion of the orbits are otherwise unremarkable impression no acute intracranial process ct abdomen pelvis impression large retroperitoneal hematoma with a hematocrit level bilateral duplicated renal collecting systems with ectopic right kidney cxr portable findings ap portable chest radiograph demonstrates a left chest cardiac pacing device leads appear intact and in unchanged position median sternotomy wires appear intact several mediastinal clips project over the left cardiac border an enteric tube descends the thorax in uncomplicated course its tip which terminates below the left hemidiaphragm not completely imaged lungs are clear without a focal consolidation heart size is enlarged without pulmonary edema there is no pneumothorax or large pleural effusion impression no focal opacity convincing for pneumonia cardiac studies tte the left atrial volume index is mildly increased left ventricular wall thicknesses are normal the left ventricular cavity is mildly dilated there is mild to moderate regional left ventricular systolic dysfunction with near akinesis of the inferior and inferolateral walls the remaining segments contract normally lvef the estimated cardiac index is normal 5l min m2 no masses or thrombi are seen in the left ventricle 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 there is no mitral valve prolapse the estimated pulmonary artery systolic pressure is high normal there is a trivial physiologic pericardial effusion impression suboptimal image quality mild left ventricular cavity dilation with regional systolic dysfunction most c w cad pda distribution no valvular pathology or pathologic flow identified clinical implications the left ventricular ejection fraction is a threshold for which the patient may benefit from a beta blocker and an ace inhibitor or discharge labs 57am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 57am blood plt 57am blood glucose urean creat na k cl hco3 angap 57am blood calcium phos mg w cad s p remote 2v cabg and pci vt and vf s p aicd hfref ef insulin dependent diabetes ckd b l cr hypothyroidism and etoh use disorder who presents as a transfer from for recurrent vt shocked times following an admission there on for a syncopal episode in the setting of vtach coronaries lhc on lcx patent w stent lima to lad patent known occluded lad rca svg to rca scg to om patent pump ef on tte rhythm monomorphic vt on admission later intermittently a v paced vt storm pt w cad and hx vt vf s p bi v aicd found to be in mmvt iso syncopal event at home w o triggering his device required multiple shocks but still had recurrent vt ultimately requiring intubation for airway protection iso multiple shocks device was interrogated revealing multiple episodes of at af lasting minutes to hours threshold was increased no evidence of new ischemic changes on ekg trop neg and cath without evidence of new worsening cad was medically managed w amio gtt lidocaine gtt and ultimately w procainamide gtt but continued to have intermittent vt was likely related to arrhythmogenic focus originating in extensive cardiac scarring secondary to lonstanding cad repeat run of monormorphic vt on which aborted with atp patient was amiodarone loaded with 11g and then continued on amiodarone po 200mg daily and carvedilol 25mg bid per ep no immediate plans to pursue ablation in inpatient setting given patient s complicated hospitalization and given no recurrent vt for over one week acute metabolic encephalopathy pt was agitated requiring precedex and was delirious only a o to place on admission noncontrast head ct negative for intracranial pathology delirium likely exacerbated from hospitalization and exacerbated by retroperitoneal bleed per s s pt had swallowing risk iso encephalopathy and dobhoff placed and patient was started on tube feeds pt s delirium improved with nonpharmacologic meausures and he was weaned from precedex he was on tube feeds until cleared by speech and swallow and advanced to regular diet upon discharge hfref ef on tte known hfref thought to be to extensive ischemic disease ef on tte at reduced from prior ef tte in house showed ef with mild lv cavity dilation with regional systolic dysfunction most c w cad pda distribution pt was noted to be volume overloaded at and was treated with iv lasix boluses until euvolemia was reached and then transitioned to lasix mg po with goal even patient s home metoprolol was switched to coreg bid upon discharge for afterload reduction patient was started on captopril which was initially transitioned to lisinopril mg daily patient had two episodes of orthostatic hypotension on and with sbps dropping from 140s supine to standing patient was lightheaded during first episode and sbps increased to 110s and patient s symptoms resolved with 500cc bolus he was asymptomatic during second episode and encouraged po intake most likely that patient was slightly hypovolemic secondary to diuresis and we therefore opted to withhold further diuresis discontinued lasix 20mg daily and reduce losartan from 30mg daily to 10mg daily after discharge patient should be reevaluated in terms of whether he needs addition of a diuretic as an outpatient and whether uptitration of losartan is warranted based on blood pressures atn reported b l is initially exacerbated in the setting of hypervolemia from cardiorenal vs hypoperfusion i s o vt storm had significantly acute worsening of cr to in the setting of retroperitoneal bleed with concern for hypovolemia dense atn on urine sediment on creatinine downtrending likely reflecting recovery from atn currently patient should have repeat chemistries within three days of discharge to ensure resolution of renal function retroperitoneal hematoma patient reported worst abdominal pain on with h h drop ct abd pelvis was obtained and showed large right retroperitoneal hematoma measuring up to x cm in the axial dimension and cm in the coronal dimension with mass effect displacing the right psoas muscle and kidney anteriorly of note patient had cath on with right femoral access administered ivf and 2u prbc and ffp x1 with appropriate bump in hematocrit as well as vitamin k once hemodynamically stable and h h stable patient was started on gdmt for hfref was above and restarted on warfarin atrial fibrillation noted on pacer interrogation patient was started on amiodarone to be continued following discharge as above he is also on carvedilol as above he was started on warfarin which is at 5mg daily at time of discharge inr at time of discharge is with goal inr patient will need baseline lfts and tfts as well as annual cxr given recent initiation of amiodarone transaminitis had transaminitis with alt ast into the low 100s likely related to being on rosuvastatin amiodarone and ezetimibe ezetime was discontinued lfts currently downtrending patient will require repeat lfts within three days to ensure resolution of transaminitis and for baseline given recent initiation of amiodarone leukocytosis wbc increased to on admission unclear etiology as patient has not been spiking fevers and has no infectious symptoms c diff negative uti ruled out with negative ucx and bcx cxr wnl however he was treated for vap as below due to recent pneumonia and recent intubation leukocytosis improved to wbc at time of discharge ventilator associated pneumonia patient had been intubated iso vt storm as above he developed a leukocytosis and was started on vancomycin ceftazadime for vap which was transitioned to ceftazadime only on and was treated for day course which ended on cad s p 2v cabg and multiple pcis hx of vt and vf w medtronix bi v aicd in place no new ischemic changes on ekg and trops flat cath on showed lcx patent w stent lima to lad patent known occluded lad rca svg to rca scg to om patent unchanged from prior likely that vt is related to extensive cardiac scarring as above patiet was continued on home aspirin mg daily and home rosuvastatin 40mg daily metoprolol was converted to carvedilolol 25mg bid for improved afterload control insulin dependent diabetes patient was taking glargine units qhs at home fsbgs were elevated into 400s during initial parts of admission endocrinology was consulted and pt s hiss was uptitrated and his glargine was increased to 30u qam and 30u qhs upon removal of dobhoff pt had reduced po intake in the setting of dysphagia diet and fsbgs dropped to 100s 200s reduced glargine to 10u qam and 10u qhs and reduced mealtime humalog from 4u to 2u with meals in spite of the less aggressive regimen pt continued to have am sugars in the although fsbgs up to 190s 200s during the day even with resumption of regular diet and improved po intake opted to continue 10u am lantus and discontinue lantus continue humalog 2u qac plus low dose humalog correction scale patient will need ongoing monitoring of sugars and modulation of insulin regimen following discharge hyperlipidemia patient was continued on home rosuvastatin 40mg daily his home ezetimibe was discontinued in the setting of transaminitis etoh withdrawal is a heavy scotch drinker w etoh use disorder had etoh on his breath in field when found by ems and found to be acidotic in ed has been tremulous requiring ativan and librium at ativan was initially continued in house but was discontinued within 24hrs when ciwas trended to patient was counseled regarding the dangers of etoh use especially in the context of being on other hepatotoxic medications including rosuvastatin and amiodarone hypothyroidism patient was continued on home levothyroxine 75mg daily code full confirmed contact hcp wife home cell discharge weight 4kg dry euvolemic discharge creatinine transitional patient s home hydrochlorothiazide 25mg daily and isosorbide mononitrate 30mg daily were discontinued patient s ezetimibe was discontinued in the setting of transaminitis patient s home apixaban was discontinued and he was started on warfarin for antiocoagulation in the setting of atrial fibrillation at time of discharge warfarin dose is 5mg daily and inr is patient will need inr rechecked on patient s home metoprolol was discontinued and he was started on carvedilol 25mg bid for improved afterload control patient was diuresed with plan to be discharged on lasix po 20mg daily have withheld diuresis in the setting of orthostatic hypotension as described please re evaluate patient for ongoing diuresis needs has cardiology follow up scheduled for this patient was started on lisinopril 30mg daily for afterload reduction dose was reduced to 10mg daily in context of orthostatic hypotension please evaluate for modulation of lisinopril dosing based on blood pressure trends patient with am fsbgs in the and then ranging from 100s 200s during the day most recent insulin regimen is glargine 10u qam humalog 2u qac and hiss that is less aggressive qhs please continue to evaluate insulin regimen following discharge patient will need baseline lfts within three days and tfts and pfts within weeks as well as annual cxr given recent initiation of amiodarone patient should have repeat lfts and chemistries within three days to ensure improvement in transaminitis and acute kidney injury if patient s hoarseness does not improve in two weeks he will need to be evaluated by ent patient was counseled regarding his etoh use disorder and especially in the context of his medications several of which are hepatotoxic e g amiodarone rosuvastatin please continue this dialogue following discharge medications on admission the preadmission medication list is accurate and complete glargine units bedtime levothyroxine sodium mcg po daily rosuvastatin calcium mg po qpm apixaban mg po bid hydrochlorothiazide mg po daily ezetimibe mg po daily metoprolol tartrate mg po daily isosorbide mononitrate extended release mg po daily nitroglycerin sl mg sl q5min prn chest pain discharge medications amiodarone mg po daily aspirin mg po daily carvedilol mg po bid folic acid mg po daily lidocaine patch ptch td qpm back lisinopril mg po daily multivitamins w minerals tab po daily thiamine mg po daily warfarin mg po daily16 glargine units breakfast humalog units breakfast humalog units lunch humalog units dinner insulin sc sliding scale using hum insulin levothyroxine sodium mcg po daily nitroglycerin sl mg sl q5min prn chest pain rosuvastatin calcium mg po qpm discharge disposition extended care facility discharge diagnosis primary diagnosis ventricular tachycardia vt storm atrial fibrillation transaminitis acute on chronic heart failure with reduced ejection fraction alcohol withdrawal retroperitoneal hematoma secondary diagnosis hypothyroidism discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr it was a pleasure taking care of you during your hospital stay at you were hospitalized here in our cardiac intensive care unit you were admitted to our intensive care unit for having rapid irregular rhythms of your heart called ventricular tachycardia we were able to change the settings on your defibrillator and also were able to change your medications to hopefully prevent this from happening in the future please continue to take all of your home medications as prescribed you will be going to a rehab center to build up your strength you should also stop drinking when you leave as this can provoke this abnormal heart rhythm wishing you the best your team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies metformin attending chief complaint pea arrest major surgical or invasive procedure vt ablation history of present illness mr is a year old man with cad s p remote vessel cabg in s p pci vt and vf s p icd implant in at most recent lvef iddm and ckd baseline cr who was transferred to the ccu post vt ablation procedure where he suffered a cardiac arrest he had recently been seen by ep on in preparation for his vt ablation an interrogation of his device had revealed multiple episodes of vt between and at the time he reported feeling occasional dizziness and weakness due to sbp running periodically in the he noted occasional palpitations and dyspnea on exertion but otherwise denied orthopnea pnd edema or chest pain of note patient had previously had complicated admission to for vt storm had been shocked times requiring intubation multiple antiarrythmics pressors eventually loaded and discharged with amiodarone cath revealed a patent cx stent and ischemia was not felt to be the cause of his arrest during the admission he had acute metabolic encephalopathy a retroperitoneal bleed post cath acute worsening of his cr to pneumonia and episodes of atrial fibrillation he was discharged to rehab home and has slowly been regaining strength on arrival to the ccu he is intubated and sedated on pressors however within an hour he is awake and following commands after recovering from sedation he is no longer requiring pressors he was awake and following commands with cough and gag spontaneous breathing trial was successful and he was extubated shortly after arrival to the ccu upon extubation he is not in pain asks for the time and knows where he is past medical history hypertension hyperlipidemia t2dm on insulin cad s p mi in his and subsequent cabg lima to lad svg to rca and om in with subsequent lcx stent hf lvef in vt vf s p dual chamber icd implant stroke about years ago denies current deficits hypothyroidism etoh use disorder mild withdrawal symptoms on previous hospitalization social history family history father htn dm early mi age dies early from cad brother cad first mi in his late mother s sisters with cancer unknown type physical exam admission exam vs face tent with humidifier s p extubation 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 neck supple jvp of cm cardiac regular rate and rhythm normal s1 s2 no murmurs lungs respiration is unlabored with no accessory muscle use no crackles mild expiratory wheeze abdomen soft non tender non distended unable to appreciate organomegaly extremities warm well perfused no clubbing cyanosis or peripheral edema skin no significant skin lesions or rashes pulses distal pulses palpable and symmetric discharge exam vs po l sitting hr rr o2 ra general well developed well nourished in nad oriented x3 mood affect appropriate heent normocephalic atraumatic sclera anicteric perrl eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa neck supple did not note jvp at deg hjr cardiac regular rate and rhythm normal s1 s2 systolic murmur at lusb lungs respiration is unlabored with no accessory muscle use bibasilar crackles to mid lung scattered expiratory wheezing abdomen soft obese non tender non distended bs extremities warm well perfused no clubbing cyanosis or peripheral edema skin no significant skin lesions or rashes pulses distal pulses palpable and symmetric pertinent results admission labs 37pm hgb calchct o2 sat carboxyhb met hgb 37pm glucose lactate na k cl 37pm po2 pco2 ph total co2 base xs 56pm type art po2 pco2 ph total co2 base xs 56pm glucose lactate na k cl 25pm hgb calchct o2 sat carboxyhb 25pm glucose lactate na k cl 25pm type art po2 pco2 ph total co2 base xs pertinent labs lytes 24am blood glucose urean creat na k cl hco3 angap 46am blood glucose urean creat na k cl hco3 angap liver enzymes 38pm blood alt ast ld ldh alkphos totbili 24am blood alt ast ld ldh alkphos totbili 46am blood alt ast ld ldh alkphos totbili coagulation labs 24am blood ptt 24am blood plt 46am blood ptt 46am blood plt discharge labs 32am blood ptt 32am blood plt 32am blood alt ast alkphos totbili 32am blood glucose urean creat na k cl hco3 angap pertinent imaging studies cxr postoperative changes left sided pacemaker no focal consolidation pathology mr has a new diagnosis of an anti c antibody the is a member of the rh blood group system anti c antibodies are clinically significant and capable of causing hemolytic transfusion reactions in the future mr should receive negative products for all red cell transfusions approximately of abo compatible blood will be negative brief hospital course mr is a m with a pmh of cad s p remote vessel cabg in s p pci vt and vf s p icd implant in at chf and ckd baseline cr who was transferred to the ccu from the ep lab in the ep lab during a vt ablation procedure the patient had an episode of vt which was refractory to atp and shock this resulted in a pea arrest with rosc after minutes of cpr and epi x2 a detailed list of all of the problems addressed during this hospitalization can be found below acute issues cardiac arrest vt and hx of vf s p icd implant pt had a pea arrest following triggered vt which was refractory to pacing termination and to dc shock the pt had rosc after minutes of cpr and epinephrine x2 post arrest the patient was intubated and on pressors with a lactate elevated to the pt was transferred to the ccu where he quickly no longer required pressors and was extubated the pt was mentating well and without any signs of hypoperfusion to his brain and with a lactate that normalized the pt had three episodes of vt in the ccu all of which were terminated by atp per ep recommendations his medications were changed from amiodarone bid to mexilitine 150mg po tid the pt had no further episodes of vt and once stable was discharged home with close follow up chronic issues transaminitis the pt has a h o elevated liver enzymes thought to be secondary to rouvastatin and amiodarone use apparent acute on chronic elevation of liver enzymes following arrest which was attributed to hypoperfusion during his pea arrest his statin was held in the setting of acute liver injury however they were restarted when his transaminases quickly normalized no further workup was pursued cad s p 3v cabg in s p pci patient s home lisinopril carvedilol and statin were all held in the setting of pea arrest hypotenstion and acute liver injury he was restarted on home meds but he was switched to metoprolol succinate 50mg po bid per ep recs heart failure ef not an active issue on this hospitalization pt continued on home regimen as above a fib noted on previous pacer interrogation on warfarin previously on xarelto that was stopped on last admission rp bleed from heparin inr elevated post arrest but therapeutic on discharge on home warfarin dose t2dm on insulin home insulin regimen leukocytosis and acute on chronic anemia resolved no infectious workup pursued ckd patient with elevated cr on last admission secondary to atn unknown previous baseline etiology likely secondary to dm htn chf hypothyroidism continued on home levothyroxine stridor has had upper airway stridor since this which can be worked up as a transitional issue transitional issues patient with down trending liver enzymes after cardiac arrest discharge ast alt please check transaminases at follow up appointment to assess for return to baseline following probable shock liver patient with acute worsening of mild inspiratory stridor and no respiratory distress after intubation he states that he has had these symptoms for a few months since last extubation in please ensure that he follows up with ent as an outpatient patient with ckd cr at time of discharge at baseline patient on warfarin for treatment of intermittent a fib inr therapeutic on discharge at patient with mild anemia and thrombocytopenia at time of discharge h h and plt please repeat cbc at follow up appointment to ensure return to baseline during hospitalization patient had episodes of non sustained vt on telemetry while on amiodarone therefore amiodarone stopped and mexiletine q8h was started to reduce ectopy patient initially with nausea that resolved after hours metoprolol xl bid was started and carvedilol was stopped to prevent hypotension new meds mexiletine 150mg po tid metoprolol succinate 50mg bid stopped meds amiodarone bid carvedilol 2mg bid code full code contact hcp relationship wife phone on admission the preadmission medication list is accurate and complete levothyroxine sodium mcg po daily rosuvastatin calcium mg po qpm amiodarone mg po daily aspirin mg po daily carvedilol mg po bid folic acid mg po daily lisinopril mg po daily thiamine mg po daily warfarin mg po daily16 nitroglycerin sl mg sl q5min prn chest pain lantus insulin glargine unit ml subcutaneous qhs humalog insulin lispro unit ml subcutaneous tid w meals centrum multivit iron min folic acid br multivit mins ferrous gluconat br multivitamin iron folic acid mg mcg oral daily discharge medications metoprolol succinate xl mg po bid rx metoprolol succinate mg tablet s by mouth twice a day disp tablet refills mexiletine mg po q8h rx mexiletine mg capsule s by mouth every eight hours disp capsule refills aspirin mg po daily centrum multivit iron min folic acid br multivit mins ferrous gluconat br multivitamin iron folic acid mg mcg oral daily folic acid mg po daily humalog insulin lispro unit ml subcutaneous tid w meals lantus insulin glargine unit ml subcutaneous qhs levothyroxine sodium mcg po daily lisinopril mg po daily nitroglycerin sl mg sl q5min prn chest pain rosuvastatin calcium mg po qpm thiamine mg po daily warfarin mg po daily16 discharge disposition home discharge diagnosis ventricular tachycardia pea arrest discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr you were admitted to the hospital after there was a complication during your ablation procedure you were monitored in the cardiac icu and on the floor and after your condition was stabilized you were discharged home below please find a detailed list of all that happened while you were in the hospital while you were in the hospital you had a ventricular ablation procedure for your history of ventricular tachycardia during the procedure you had ventricular tachycardia which was unable to be stopped at this time your heart stopped beating and you were given chest compressions and medications to help your heart start beating again you had a breathing tube inserted and you were given medications to help support your blood pressure you were brought to the cardiac icu where your breathing tube was removed and you no longer required medications to control your blood pressure you had some more episodes of ventricular tachycardia which were all stopped by your pacemaker the electrophysiology team saw you and made adjustments to your medications to try to stop these episodes when you were no longer having episodes of ventricular tachycardia you were discharged home with close follow up with the cardiology team when you leave if you notice a weight gain of more than pounds over a couple days please see your cardiologist please take all of your medications as prescribed for you please attend all of your follow up appointments call to make a follow up appointment with ent for your hoarseness and stridor while breathing it was a pleasure to care for you during your hospitalization your team followup instructions

name unit no admission date discharge date date of birth sex f service surgery allergies penicillins attending chief complaint s p fall back pain major surgical or invasive procedure none history of present illness is a year old woman with a history of pmr on a prednisone taper osteoporosis prior thoracic compression fractures who presented to the ed on with weeks of atraumatic back pain which which acutely worsened yesterday after leaning back to sit in her recliner but fell onto her buttocks she is typically independent and fully mobile at baseline she was evaluated by ortho spine who recommended tlso brace for comfort ed obs for pain control and a evaluation she was evaluated by who found the patient to be motivated to return home and engage in outpatient physical therapy today the patient has been ambulating at baseline however in certain positions such as leaning forward or standing her back pain increases she states she prefers to be admitted for one more night for pain control before going home on exam the patient still denies fevers chills chest pain palpitations nausea vomiting numbness tingling weakness saddle anesthesia loss of bowel or bladder function past medical history past medical surgical history pmr osteoporosis thoracic compression fractures mgus glaucoma social history family history noncontributory physical exam admission physical exam gen nad a ox3 pleasant conversant heent normocephalic atraumatic sclera anicteric neck trachea midline supple no c spine tenderness resp breathing comfortably on room air cv rrr back tender to palpation in lower thoracic spine upper lumber spine abd soft non tender non distended ext warm well perfused minimal edema no abrasions or lacerations noted discharge physical exam vs ra gen a o x3 sitting up in chair nad heent wnl cv hrr pulm ls ctab abd soft nt nd ext wwp no edema neuro low back pain pertinent results imaging ct head there is no evidence of acute intracranial hemorrhage midline shift mass effect or acute large vascular territorial infarct mild periventricular and subcortical white matter hypodensities are nonspecific extensive calcifications are seen along the cavernous portions of the bilateral carotid arteries vertebral artery calcification is also noted ct chest compression deformities of t8 t10 and l1 vertebral bodies compatible fractures of unknown chronicity l1 fx has acute subacute appearance question of r 3rd rib nondisplaced fx ct c spine multilevel degenerative changes of c spine no evidence of acute fx or traumatic malalignment brief hospital course ms is a year old woman with a history of pmr on a prednisone taper osteoporosis prior thoracic compression fractures who presented to the ed on with weeks of atraumatic back pain which acutely worsened found to have t8 t10 l1 compression fracture acute vs subacute she was admitted to the acute care surgery service for pain management ortho spine was consulted who recommended no surgical intervention tlso for comfort and no bending or twisting on the floor she was advanced to a regular diet her home medication was restarted she was started on oral medication for pain control with good affect the tlso brace was ordered and came to bedside but the patient stated she was unable to the brace by herself she was evaluated by physical therapy who felt she would need to go to rehab at the time of discharge she was afebrile and hemodynamically stable pain was well controlled on oral medication alone tolerating a regular diet voiding adequately and spontaneously she was ambulating with assistance in the tlso and she was deemed stable for discharge to rehab she was discharged home with appropriate instructions and follow up and verbalized agreement with the plan medications on admission the preadmission medication list is accurate and complete prednisone mg po daily latanoprost ophth soln drop both eyes qhs dorzolamide ophth soln drop both eyes tid discharge medications acetaminophen mg po tid lidocaine patch ptch td qpm rx lidocaine lidocaine pain relief apply one to lower back daily once a day disp patch refills polyethylene glycol g po daily senna mg po bid prn constipation tramadol mg po q6h prn pain severe rx tramadol mg tablet s by mouth every six hours disp tablet refills vitamin d unit po daily dorzolamide ophth soln drop both eyes tid latanoprost ophth soln drop both eyes qhs prednisone mg po daily discharge disposition home with service facility discharge diagnosis t8 t10 l1 compression fracture subacute r 3rd rib fx discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms you were admitted to the hospital after you sustained a fall and were found to have a several spine compression fractures unclear whether acute or chronic and a subacute right 3rd rib fracture you were treated with oral pain medication you were seen by physical therapy who recommended you be discharged home with home physical therapy you are now ready for discharge home please follow these instructions to aid in a speedy recovery please call your doctor or nurse practitioner or return to the emergency department for any of the following you experience new chest pain pressure squeezing or tightness new or worsening cough shortness of breath or wheeze if you are vomiting and cannot keep down fluids or your medications you are getting dehydrated due to continued vomiting diarrhea or other reasons signs of dehydration include dry mouth rapid heartbeat or feeling dizzy or faint when standing you see blood or dark black material when you vomit or have a bowel movement you experience burning when you urinate have blood in your urine or experience a discharge your pain in not improving within hours or is not gone within hours call or return immediately if your pain is getting worse or changes location or moving to your chest or back you have shaking chills or fever greater than degrees fahrenheit or degrees celsius any change in your symptoms or any new symptoms that concern you please resume all regular home medications unless specifically advised not to take a particular medication also please take any new medications as prescribed please get plenty of rest continue to ambulate several times per day and drink adequate amounts of fluids if you have any questions you may reach the acute care surgery clinic at the following number best wishes your surgery team followup instructions

name unit no admission date discharge date date of birth sex f service neurology allergies lisinopril attending chief complaint dysarthria major surgical or invasive procedure none history of present illness she states around 12am last night she suddenly noticed that her mouth felt very heavy her daughter asked if she took her bp medication yet she had not so proceeded to do so she states she felt better after taking medication in the morning she continued to have these symptoms so she called her brother who told her to call other family noted slurred speech when she spoke to her somewhere between today she denies numbness states it just felt heavy in her mouth states she has coughing after swallowing things occasionally not sure if it is new today during interview she is coughing a lot after getting medications with water from nursing she denies any other symptoms denies weakness or numbness no problems with language no double vision reports she has intermittent dizziness if she doesn t take one of her medications she is not sure which one of these medications helps with dizziness denies room spinning more of a lightheadedness family does not think speech is currently at baseline and think she sounds dysarthric her bottom dentures are not in right now she doesn t normally keep the bottom ones in family states speech is different compared to when she doesn t wear bottom denture as well they think it seems like she is talking from the side of her mouth during interview she states the heaviness in her mouth has felt improved since she came to the ed denies dysuria reports urinary frequency denies having tia in the past on neuro ros the pt denies headache loss of vision blurred vision diplopia vertigo tinnitus or hearing difficulty denies difficulties producing or comprehending speech denies focal weakness numbness parasthesiae no bowel or bladder incontinence or retention denies difficulty with gait on general review of systems the 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 t2dm hld htn social history family history relative status age problem onset comments other sh fh son living hypertension end stage renal on hd disease physical exam admission physical exam vitals t p r bp sao2 general awake cooperative nad heent nc at no scleral icterus noted mmm no lesions noted in oropharynx neck supple no carotid bruits appreciated no nuchal rigidity pulmonary lungs cta bilaterally without r r w cardiac rrr nl 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 able to relate history without difficulty attentive able to name backward somewhat slowly language is fluent with intact repetition and comprehension normal prosody there were no paraphasic errors pt was able to name both high and low frequency objects able to read without difficulty speech was perhaps slightly dysarthric per family somewhat difficult to understand due to accent for interviewer able to follow both midline and appendicular commands there was no evidence of apraxia or neglect cranial nerves ii iii iv vi perrl to 2mm and brisk eomi without nystagmus normal saccades vff to confrontation visual acuity bilaterally 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 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 normal stride and arm swing able to walk in tandem without difficulty romberg absent discharge physical exam physical exam vitals hr data last updated temp tm bp hr rr o2 sat o2 delivery ra wt lb kg general awake cooperative nad heent nc at no scleral icterus noted mmm no lesions noted in oropharynx neck supple no carotid bruits appreciated no nuchal rigidity pulmonary breathing comfortably on room air cardiac rrr nl s1s2 no m r g noted abdomen non distended extremities no edema skin no rashes or lesions noted neurologic mental status awake and alert able to relate history without difficulty attentive language is fluent normal prosody there were no paraphasic errors no dysarthria noted cranial nerves eomi left facial droop improved from prior tongue midline motor normal bulk tone throughout no pronator drift bilaterally no adventitious movements such as tremor noted no asterixis noted sensory no deficits to light touch dtrs deferred no intention tremor no dysdiadochokinesia noted no dysmetria on fnf or hks bilaterally gait good initiation normal stride and arm swing able to walk in tandem without difficulty pertinent results admission labs 36am blood plt 36am blood im 55am blood 36am blood 36am blood important labs 55am blood 55am blood 55am blood imaging cta head and neck ct head shows no evidence of hemorrhage or loss of matter differentiation no midline shift or hydrocephalus seen ct angiography of the neck shows normal appearance of the carotid and vertebral arteries without stenosis or occlusion or dissection mild vascular calcifications are seen ct angiography of the head shows normal appearance of the arteries of the anterior and posterior circulation without stenosis or occlusion or aneurysm greater than mm in size mild vascular calcifications are seen at the cavernous carotid artery impression no significant abnormalities on ct of the head without contrast no significant abnormalities on ct angiography of the head and neck tte the left atrial volume index is normal no thrombus mass is seen in the body of the left atrium best excluded by tee 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 no thrombus or mass is seen in the left ventricle the visually estimated left ventricular ejection fraction is 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 the aortic valve leaflets appear structurally normal no masses or vegetations are seen on the aortic valve there is no aortic valve stenosis there is trace aortic regurgitation the mitral valve leaflets appear structurally normal with no mitral valve prolapse no masses or vegetationsare seen on the mitral valve there is trivial mitral regurgitation the tricuspid valve leaflets appeastructurally normal no mass vegetation are seen on the tricuspid valve there is physiologic tricuspidregurgitation the estimated pulmonary artery systolic pressure is normal there is no pericardial effusion i mpression normal biventricular cavity sizes regional global systolic function no valvular pathology or pathologic flow identified normal estimated pulmonary artery systolic pressure no structural cardiac source of embolism e g patent foramen ovale atrial septal defect intracardiac thrombus or vegetation seen no prior tte available for comparison mri head there is restricted diffusion right corona radiata and right putamen with associated t2 signal hyperintensity consistent with an early subacute infarct evaluation for intracranial hemorrhage is limited as gre sequence was not obtained there is no t1 hypointensity to suggest subacute blood there is no significant mass effect there is mild prominence of the ventricles and sulci consistent with involutional changes numerous subcortical deep and periventricular white matter and pontine t2 signal hyperintensities are nonspecific however likely represent sequela of chronic small vessel ischemic disease the major intracranial flow voids are preserved there is minimal mucosal thickening in the ethmoid air cells there is trace fluid in the right mastoid air cells the orbits are grossly unremarkable impression incomplete exam early subacute infarct in right corona radiata and right putamen no significant mass effect brief hospital course f w pmh t2dm htn hld presents with acute onset mouth heaviness and dysphagia found to have acute ischemic stroke plan right corona radiata and right putamen initial imaging showed some atherosclerotic disease on ct she did not receive tpa or thrombectomy because there was not lvo she was outside window for tpa and nihss was too low mri showed right corona radiate and right putamen acute infarct mri was incomplete so no gre sequence was done tte was negative for any cardiac source of embolus she was continued on aspirin 81mg as patient was not taking medications as prescribed at home risk factors were checked and were ldl hgba1c etiology of stroke was felt to be small vessel iso uncontrolled htn diabetes and hyperlipidemia she was switched from pravastatin to rosuvastatin she was initially started on atorvastatin but this caused gi upset htn blood pressure was allowed to autoregulate after acute ischemic stroke she was restarted on half amlodipine dose at discharge sbp during admission ranged from she will follow up with her pcp for further management of blood pressure diabetes hgba1c checked and was elevated to looking back through notes patient has had difficulty controlling diabetes and frequently does not take her medications she was seen by while inpatient she was requiring very minimal correction doses of sliding scale insulin per patient she has not been taking her metformin because it causes significant gi upset in addition it is unclear how often patient takes glipizide as well therefore given minimal insulin requirements it was felt that patient could be discharged on glipizide once a day only and this should control her blood glucose if she is compliant she was told this and encouraged to take her medications as prescribed she will be discharged with to help with medication compliance and to monitor if she is tolerating medications in addition she was enrolled in elder services and social work will follow as an outpatient uti ua was consistent with infection and culture grew ecoli she was treated with ceftriaxone for day course transitional issues patient discharged with home services and home social work in addition she was enrolled in elder services consider medication delivery in blister package to help with compliance patient discharged on 5mg amlodipine after acute infarct can increase as needed for blood pressure control please assess if patient is tolerating medications if she is continuing to get gi upset with diabetes medications can consider switching to injectable speech and swallow recommended soft solids with thin liquids and for medications to be taken whole in puree 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 x yes no if ldl reason not given statin medication allergy other reasons documented by physician advanced practice nurse physician physician apn pa or pharmacist less than mg dl smoking cessation counseling given yes x no reason x unable to participate stroke education personal modifiable risk factors how to activate ems for stroke stroke warning signs and symptoms prescribed medications need for followup given verbally or written x yes no assessment for rehabilitation or rehab services considered x yes no if no why not i e patient at baseline functional status discharged on statin therapy x yes no if ldl reason not given statin medication allergy other reasons documented by physician advanced practice nurse physician physician apn pa or pharmacist less than mg dl discharged on antithrombotic therapy x yes type x antiplatelet anticoagulation no discharged on oral anticoagulation for patients with atrial fibrillation flutter yes no if no why not i e bleeding risk etc x n a medications on admission the preadmission medication list is accurate and complete amlodipine mg po daily aspirin mg po daily brimonidine tartrate ophth drop both eyes q8h chlorthalidone mg po daily glipizide mg po bid metformin xr glucophage xr mg po bid pravastatin mg po qpm discharge medications rosuvastatin calcium mg po qpm rx rosuvastatin mg tablet s by mouth at bedtime disp tablet refills amlodipine mg po daily rx amlodipine mg tablet s by mouth daily disp tablet refills glipizide mg po daily aspirin mg po daily brimonidine tartrate ophth drop both eyes q8h held chlorthalidone mg po daily this medication was held do not restart chlorthalidone until you follow up with your pcp home with service facility discharge diagnosis primary diagnosis acute ischemic stroke secondary diagnosis htn hld diabetes type ii discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms you were hospitalized due to symptoms of difficulty speaking and eating resulting from an acute ischemic stroke a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot the brain is the part of your body that controls and directs all the other parts of your body so damage to the brain from being deprived of its blood supply can result in a variety of symptoms stroke can have many different causes so we assessed you for medical conditions that might raise your risk of having stroke in order to prevent future strokes we plan to modify those risk factors your risk factors are high blood pressure high lipids diabetes we are changing your medications as follows stop taking pravastatin start taking rosuvastatin your dose of amlodipine was decreased to 5mg please take this until you see your pcp glipizide dose was reduced please only take this once a day please take your aspirin diabetes medications and blood pressure medications as directed this is very important 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 medicine allergies lisinopril rosuvastatin attending chief complaint weakness nausea major surgical or invasive procedure none history of present illness with t2dm htn hld h o stroke and tia h o depression ptsd and multiple ed visits presents with dizziness and weakness here with multiple nonspecific symptoms including weakness dizziness headache and poor appetite her overall presentation is similar to those from prior ed visits and is most consistent with likely deconditioning and failure to thrive at home patient indicates that she has been experiencing weakness x months dizziness x months ha and nausea x day weeks the headache has been worse in the past week the dizziness has not changed the nausea is accompanied by dizziness and was accompanied by abdominal pain yesterday prompting her ed visit she experiences whole body weakness particularly in her legs her weakness prevents her from doing activities she usually does like lawncare although she says she still has interest in performing those activities her weakness and overall health prevent her from going to which she finds upsetting as she has not been able to visit her elderly aunt she states she has lost her appetite and has lost pounds 170lb 130lb over the past two month per report she states that she usually eats bread tea coffee and food that her daughter makes she requested a meal several times during the interview she experiences headaches that she describes as pain and pressure and all around her head traveling down her neck and back she also feels the headache in her r ear the headache is sometimes preceded by scalp itchiness and accompanied by nausea but no photophobia or phonophobia yesterday she experienced an episode of vertigo room spinning for her headaches she uses a lidocaine patch for relief and says acetaminophen provides no relief the headache comes and goes and occurs once a week or less she is concerned that her headaches are indicative of cancer or a neurological problem val indicates she had an episode of presyncope that was associated with some epigastric tightness nausea shortness of breath patient endorses frequent leg cramps for which she drinks water and uses ice she states that she sometimes sleeps little she reports occasional subjective fevers cold sweats during the day coinciding with elevated bp but denies night sweats records indicate that she did not do well with and needs additional therapy but is not eligible for rehab she states that she last had physical therapy before her husband died years ago records state her family is not comfortable going home with services at this time concerned about safety at home she says she has good support at home from her children but feels she needs more support three prior ed visits since for similar complaints most recently reported to ed on physical exam was notable for diffuse lower abdominal tenderness without rebound guarding or peritonitic signs ua cbc cmp electrolytes within normal limits cxr and ct abd and pelvis both unremarkable case management was consulted and worked to arrange additional services at home in the ed she ate remained ambulatory and received hydration she was discharged home the same day past medical history dm2 htn hld stroke tia depression ptsd glaucoma constipation headaches insomnia social history family history mother deceased at mi in cause of death htn father deceased at dm died of complications son living htn esrd daughter dm cousin deceased brain cancer cause of death physical exam admission exam general pleasant and lying comfortably in bed no apparent distress heent ncat peerl mmm oropharynx clear pseudonystagmus minimal temporal wasting neck supple trachea midline no cervical or supraclavicular lad cv rrr no mrg lungs ctab no wheezes rales or rhonchi abd soft ntnd extremities wwp no edema neuro mental status aaox3 good attention strength in bue and ble sensation intact to light touch diffusely notes tingling in toes longstanding due to diabetic neuropathy per her report cerebellar finger nose testing intact cn ii xii intact speech fluent normal rate psych appropriate affect and behavior but cries when discussing the remote deaths of her mother and husband and her inability to go to discharge exam general pleasant and lying comfortably in bed no apparent distress heent ncat peerl mmm oropharynx clear eomi with minimal pseudonystagmus minimal temporal wasting neck supple trachea midline no cervical or supraclavicular lad cv rrr no mrg lungs ctab no wheezes rales or rhonchi abd soft ntnd extremities wwp no edema neuro mental status aaox3 good attention strength in bue and ble sensation intact to light touch diffusely notes numbness in toes longstanding due to diabetic neuropathy per her report cerebellar finger nose testing intact gait slow stable gait cn ii xii intact speech fluent normal rate psych appropriate affect and behavior pertinent results admission labs 15pm blood hba1c eag 15pm blood ptt 27pm urine blood neg nitrite neg protein neg glucose neg ketone neg bilirub neg urobiln neg ph leuks neg 15pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso pertinent labs 10am blood caltibc ferritn trf 15pm blood hba1c eag 10am blood tsh 26am blood cortsol 15pm blood hiv ab neg discharge labs 16am blood glucose urean creat na k cl hco3 angap 16am blood calcium phos mg imaging reports ct chest impression no acute intrathoracic process ct abdomen impression no acute intra abdominal process no findings to explain symptoms microbiology none brief hospital course summary ms is a year old woman with t2dm htn hld h o stroke and tia depression ptsd and multiple recent ed visits with dizziness and weakness here with multiple similar complaints including weakness dizziness headache and poor appetite her overall presentation was concerning for deconditioning and failure to thrive from lack of significant support at home her home antihypertensives were held as patient s bp was soft at times she was neurologically without concerning findings monitored on telemetry without significant events discharged home per recommendation of physical therapy acute issues weakness failure to thrive patient had presented to the ed multiple times for similar complaints of chronic weakness neurological exam was notable for strength diffusely and lack of significant neurological deficits physical therapy evaluated the patient and recommended rehab to increase stamina on review of her social situation and per discussion with her primary providers there is concern that the patient is not receiving a sufficient level of support at home from her daughter who lives with her and her younger daughter who lives downstairs social work met with her and shared information for elder services referral with pt and daughter pt does not require at this time per discussion with daughter pts children are available to assist with medication management and meals but that pt denies problems with hoarding and is unlikely to allow family or outside providers to address excess of belongings in her home dizziness relative hypotension history of hypertension neurologically intact on admission and throughout admission bp was soft to the initially after receiving her home amlodipine and chlorthalidone in the ed per collateral patient self titrates antihypertensives at home suspect that she has relative hypotension that is causing her dizziness no neurological exam findings hence low concern for neurological process morning cortisol normal given ivf resuscitation and stopped home antihypertensives this admission with normalization of bps loss of appetite report of weight loss patient reports subjective weight loss of lbs in the past months but omr records do not indicate significant weight change she does appears malnourished and she may indeed by having some component of weight loss associated with improved a1c from to in less than a year while on glyburide etiology of loss of appetite is multifactorial including from potentially untreated depression and a component that is secondary to her background social situation has undergone routine mammography ct a p without alarming findings no recent vaginal bleeding and no history of smoking or alcohol use hence overall felt that her risk of advanced malignancy to be very low cxr clear and no other findings to suggest advanced disseminated tb hiv negative tsh normal morning cortisol normal nutrition saw the patient and provided supplements headache appear tension type vs caffeine withdrawal patient notes that she drinks cups of coffee a day at home no neurological signs no evidence of significant nausea or vomiting to suggest increased intracranial pressure and head ct around weeks before admission as without significant findings given tylenol small dose ibuprofen and topical agents this admission encouraged to drink coffee in house subjective fevers per patient none measured at home or recorded in house depression ptsd at presentation patient was teary discussing the death of her husband years ago the death of her mother in and her inability to return home to and visit her elderly aunt in phq this admission though many of her findings were attributed to feeling weak does not appear psychosocially slow and she often has a positive affect social work constipation put on standing bowel regimen with improvement chronic issues t2dm glipizide may be contributing to presentation a1c in at this admission stopped home glyburide and put on humalog sliding scale hld prescribed rosuvastatin at home but there is a listed allergy nausea vomiting patient refused rosuvastatin omr indicates she was on rosuvastatin initially but switched to a different statin as rosuvastatin made her vomit at one point she was on atorvastatin but requested to be switched back to rosuvastatin in the past she has taken pravastatin and simvastatin which made her mouth burn home rosuvastatin was held and patient is encouraged to discuss statin choice with pcp transitional issues please discuss switching from rosuvastatin to a different statin please discuss therapy and antidepressants in order to address patients depressed mood min spent on discharge planning including face to face time medications on admission the preadmission medication list is accurate and complete amlodipine mg po daily aspirin mg po daily brimonidine ophthalmic eye bid chlorthalidone mg po daily glipizide mg po bid lidocaine patch ptch td qam rosuvastatin calcium mg po qpm senna mg po bid prn constipation first line discharge medications multivitamins w minerals tab po daily ondansetron odt mg po q8h prn nausea vomiting first line rx ondansetron mg tablet s by mouth three times per day disp tablet refills polyethylene glycol g po bid simethicone mg po qid prn gas senna mg po bid aspirin mg po daily brimonidine ophthalmic eye bid lidocaine patch ptch td qam held amlodipine mg po daily this medication was held do not restart amlodipine until talking with your doctor held chlorthalidone mg po daily this medication was held do not restart chlorthalidone until talking with your doctor held glipizide mg po bid this medication was held do not restart glipizide until talking with your doctor held rosuvastatin calcium mg po qpm this medication was held do not restart rosuvastatin calcium until talking with your doctor discharge disposition home discharge diagnosis failure to thrive 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 our pleasure taking care of you at the what brought you to the hospital you were having dizziness headaches weakness and poor appetite at home what happened in the hospital we examined you and found your neurological exam to be normal we determined that your blood pressure was lower than your usual this likely is causing your dizziness we stopped your blood pressure medications and your blood pressure became better we gave you medications and topical agents for your headache we monitored your heart rhythm using a monitor and did not find significant abnormalities we checked your blood work consistently and did not find significant abnormalities our physical therapists saw you and recommended that you get stronger in rehab our nutritionists saw you and provided recommendations about how to improve your nutrition our social workers what should you do once you leave the hospital please take your medications as prescribed and attend doctor s appointments please work hard in rehab to get stronger 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 no known allergies adverse drug reactions attending chief complaint hip pain major surgical or invasive procedure none history of present illness w hx of htn presented to the ed with pelvis pain and was found to be confused so was admitted to medicine for pain control and confusion workup he was seen here on with a diagnosis of pelvic ramus fracture kept overnight for and cm sent home with a walker and home services he returned today with continued pain he says it is not worse but it is not better either and it is limiting his ability to function at home he has been taking tylenol and ibuprofen is still able to ambulate in the ed initial vitals were ra his labs revealed h h of chem7 wnl imaging revealed bilateral lenis distal isolated tibial vein thrombosis no evidence dvt hip pelvic films minimally displaced and comminuted fractures involving the left superior and inferior pubic rami not significantly changed in overall appearance relative to prior examinations dated no new fracture is seen he received po tramadol ultram mg po tramadol ultram mg po acetaminophen mg po ng acetaminophen mg po olanzapine mg ivf meq potassium chloride ml ns he was going to be discharged from the ed however woke up this morning altered head ct was negative he was admitted to the floor for further work up for altered mental status on the floor with the assistance of a interpreter the patient says that he has pain in his legs he is confused so did not answer any other ros questions past medical history per wife htn only social history family history not pertinent to current admission physical exam admission exam vital signs ra general lying in bed no acute distress heent sclera anicteric mmm oropharynx clear no jvd perrl cv regular rate and rhythm normal s1 s2 no murmurs rubs gallops lungs ctab no w r c 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 cn ii xii grossly intact strength in upper extremities lower extremity exam limited by pain but has strength on plantarflexion of feet discharge exam vital signs ra general lying in bed appears comfortable heent head at nc perrl eomi cv regular rate and rhythm normal s1 s2 no murmurs rubs gallops lungs ctab anteriorly only no w r c abdomen soft non tender non distended bowel sounds present no organomegaly no rebound or guarding gu no foley ext legs slightly cool to touch well perfused pulses no clubbing cyanosis or edema neuro cn ii xii grossly intact moving all extremities spontaneously a ox3 pertinent results admission labs 35pm glucose urea n creat sodium potassium chloride total co2 anion gap 35pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 35pm neuts lymphs monos eos basos im absneut abslymp absmono abseos absbaso 35pm glucose urea n creat sodium potassium chloride total co2 anion gap 47pm urine rbc wbc bacteria few yeast none epi trans epi 47pm urine blood neg nitrite neg protein tr glucose neg ketone bilirubin neg urobilngn neg ph leuk neg 47pm urine color yellow appear clear sp discharge labs 34am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 34am blood glucose urean creat na k cl hco3 angap 34am blood calcium phos mg imaging ct head w o contrast impression no acute intracranial process small vessel disease with age related involutional change chest single view no acute intrathoracic process bilat lower ext veins impression nonocclusive thrombus in a single posterior tibial vein on the left no evidence of deep venous thrombosis in the right lower extremity veins dx pelvis hip unilate impression minimally displaced and comminuted fractures involving the left superior and inferior pubic rami not significantly changed in overall appearance relative to prior examinations dated no new fracture is seen microbiology ucx consistent with skin flora bcx x ngtd brief hospital course brief summary mr is a pleasant m s p fall and fracture of the left inferior and superior pubic rami on who presented with ongoing pain hip pain and was noted to be confused while in the ed and was found to have a superficial clot of the right lower tibial vein he was evaluated for causes of delirium with no obvious abnormality the likely cause of his delirium was pain medication effect he was initially treated with oxycodone mg for pain lack of sleep he did not sleep at all the night prior to his confusion and being hospitalized in the setting of chronic small vessel disease of the brain with normalization of his sleep wake cycle limiting sedating medications and administration of fluids he had significant improvement in his mental status and was discharged to rehab acute issues delirium the patient was noted to be confused upon waking the morning after being seen in the emergency department for continued hip pain in the setting of a pubic ramus fracture two weeks prior to admission he was admitted to the medicine service where he underwent a workup for causes of delirium while on the floor he exhibited waxing and waning of his mental status ranging from a ox3 to somnolent and barely interactive a general delirium workup was performed and was negative see labs for further details the likely cause of his delirium was a combination of pain medication effect he was initially treated with oxycodone mg for pain lack of sleep he did not sleep at all the night prior to his confusion and being hospitalized in the setting of chronic small vessel disease of the brain he underwent a head ct in the ed which was negative for acute findings we acquired records from a stay at in at which time he was evaluated for slowing of speech movement with concern for disease an mri brain from that stay showed enlarged cerebral ventricles with question of nph given that he was acutely delirious had fallen recently and was having incontinence while on the floor we had our radiologists read the mri from the outside hospital they felt that there was no change in the size of his ventricles from this mri versus his ct scan this admission the patient was given fluids seroquel for sleep and was put on delirium precautions with improvement in his mental status he was discharged to rehab and will follow up at with a neurologist later in the month for further evaluation per the patient s wife tibial vein thrombosis the patient has a superficial tibial vein thrombosis but with no evidence of dvt no need to anticoagulate given superficiality of clot pelvic fracture sustained fracture of his superior and inferior left pelvic ramus on with no need for operative management per orthopedics he went home with a walker but had continued pain so returned as above his pain was initially treated with oxycodone mg and standing tylenol but the oxycodone was discontinued due to concern for worsening of his delirium as above chronic issues hypertension the patient has a hx of htn controlled with prn metoprolol per wife on presentation to the floor patient had sbp to so was give mg of po captopril he was placed on captopril mg tid with improvement in pressures however he did experience sbps in the so his captopril was discontinued he may need addition of an antihypertensive as an outpatient depending on his blood pressure control normocytic anemia iron studies were performed and were consistent with anemia of chronic disease his iron was wnl tibc low normal and ferritin elevated his h h remained stable during his course transitional issues the patient was noted to have labile blood pressures with his initial sbp at he was placed on captopril mg tid with improvement in his pressures but did experience a couple of sbps in the this medication was discontinued prior to discharge and his blood pressures should be further evaluated with possible addition of antihypertensive medication the patient was noted to have a normocytic anemia with hgbs in the iron studies were consistent with anemia of chronic disease the patient was evaluated for possible disease at in after experiencing slowing of speech movement per his wife he has an appointment w neurology at on for further evaluation the patient was started on seroquel mg qhs for problems with sleep wake cycle however he experienced cognitive slowing so this was discontinued he may be sensitive to antipsychotics given his possible disease per the patient s pcp he takes sinemet tab bid for disease but the patient was reluctant to take any psychoactive medications due to concern for possible cognitive side effects code full contact wife medications on admission the preadmission medication list is accurate and complete aspirin mg po daily carbidopa levodopa tab po daily docusate sodium mg po bid lovaza omega acid ethyl esters gram oral bid vitamin d unit po daily discharge medications aspirin mg po daily docusate sodium mg po bid vitamin d unit po daily acetaminophen mg po q6h lovaza omega acid ethyl esters gram oral bid carbidopa levodopa tab po daily discharge disposition extended care facility discharge diagnosis delirium superficial tibial vein thrombosis hypertension discharge condition mental status confused sometimes level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear mr you were admitted to the hospital after you were found to be confused while visiting the emergency department due to leg pain we performed several tests to identify the cause of your confusion but no cause was found it is likely that your confusion was caused by a combination of pain pain medications which can be sedating being in a different environment lack of sleep and having some chronic age related brain changes you were also found to have a small clot in your right leg but this did not need treatment you were seen by our physical therapists who recommended rehab you were discharged to a rehab facility to help you get stronger we wish you the best your care team followup instructions

name unit no admission date discharge date date of birth sex m service surgery allergies beta blockers beta adrenergic blocking agts attending chief complaint stercoral perforation major surgical or invasive procedure sigmoid resection end colostomy history of present illness mr is pmh significant for erectile dysfunction s p inflatable penile prosthesis years ago cll severe respiratory compromise afib on coumadin who presented to for abdominal distention pain and acute urinary retention patient relays that he has not voided since yesterday multiple catheterization attempts failed and urology was consulted for foley placement this was performed without issues past medical history past medical history allergic rhinitis asthma chronic lymphocytic leukemia hld htn insomnia sleep apnea back pain with lumbar radiculopathy shoulder pain spinal stenosis congestive heart failure atrial fibrillation restless leg syndrome past surgical history penile prostesis years ago social history family history nc physical exam deceased pertinent results n a brief hospital course mr was admitted on for sterocoral perforation of unknown etiology he underwent emergent sigmoid resection end colostomy on the same date his postoperative course was complicated by afib w rvr for which he was transferred to the icu and placed on dilt gtt he experienced some respiratory decline requiring solumedrol bipap and additional diuresis with lasix over the preceding few days he became intermittently febrile and hypotensive requiring pressors hypoxic requiring intubation and ventilator support he was cdiff positive and treatment was initiated the appropriate consult services assistance were sought including renal hematology on the evening of mr worsening clinical status and goals of care were discussed with his wife and other family members present at bedside and they made the decision to terminally extubate him initiate cmo care and start morphine gtt he was pronounced dead appx hours following extubation medications on admission the preadmission medication list is accurate and complete fluticasone salmeterol diskus inh ih bid temazepam mg po qhs prn insomnia ipratropium albuterol neb neb neb q6h bumetanide mg po bid gabapentin mg po qam gabapentin mg po q5pm gabapentin mg po qhs azelastine mcg nasal daily ropinirole mg po qpm warfarin mg po daily16 mirtazapine mg po qhs tamsulosin mg po qhs simvastatin mg po qpm fluticasone propionate nasal spry nu daily diltiazem extended release mg po daily montelukast mg po daily finasteride mg po daily oxycodone acetaminophen 5mg 325mg tab po q6h prn pain mild discharge medications na discharge disposition expired discharge diagnosis deceased discharge condition deceased discharge instructions na followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies penicillins bactrim ds purinethol simvastatin lovastatin pravastatin fosamax niaspan extended release cholest off colestipol citalopram attending chief complaint weakness ams major surgical or invasive procedure none history of present illness cc weakness ams hpi female with moderate to severe dementia on treatment for c difficile ulcerative colitis presents with presyncope altered mental status per ed patient had recurrence of diarrhea yesterday today she was increasingly weak and fatigued not acting as her normal self the family believes that she was sufficiently weak that they believe that she was close to passing out they report that her mental status is improved at the time of evaluation the patient denies any active pain denies any fevers family denies any history of cough fevers report of abdominal pain vomiting per ed she is currently being treated for c diff per ed has pna and uti will treat with rocephin and azithro per nursing patient presents after experiencing a near syncopal episode earlier today patient is actively being treated for cdiff with po vanco per family patient became drowsy and talking slow and denies loc denies hitting head injury denies complaints reports decreased po intake i reviewed vs labs orders imaging old records vss hr on arrival bp was improved w ivf rr at max satting well past medical history past medical surgical history prothombin gene mutation arthritis sciatica total abdominal hysterectomy heart murmur impaired fasting glucose insomnia hypercholesterolemia allergic rhinitis gastroesophageal reflux heart murmur hypercholesterolemia impaired fasting glucose osteopenia prothombin gene mutation ulcerative colitis obesity dementia social history family history family history relative status age problem onset comments mother dementia father lung cancer smoker sister leukemia brother living brother living son living prothrombin gene son living deep venous thrombophlebitis prothrombin gene 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 soft diffusely tender abdomen 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 pertinent results admission labs 35pm 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 plt 35pm blood glucose urean creat na k cl hco3 angap 35pm blood alt ast alkphos totbili 20pm blood calcium phos mg 55am blood caltibc ferritn trf 43pm blood po2 pco2 ph caltco2 base xs 28am blood lactate discharge labs micro ucx yeast stool cx negative ucx mixed flora bcx pending studies ekg nsr at bpm lad pr qrs qtc twi iii similar to ekg nsr at bpm borderline lad pr qrs qtc twi iii v3 qtc increased from in cxr the patient is rotated limiting evaluation however persisting opacities in the right lower lung are likely not significantly changed nchct exam is limited by motion despite multiple attempted repeats within this limitation there is no acute intracranial process cxr probable right lower lobe pneumonia brief hospital course w dementia uc on prednisone mesalamine c diff on po vanco since p w diarrhea and presyncopal episode pre syncopal episode ams possible uti possible cap the patient presented with confusion and a near syncopal episode likely in the setting of increased diarrhea and hypovolemia secondary to undertreated c diff patient reportedly non adherent to po vancomycin wbc initially electrolytes and lactate wnl ua positive although patient without clear urinary symptoms and ucx with mixed flora likely contaminated repeat with yeast cxr with possible rll pneumonia but no clear respiratory symptoms nchct negative for intracerebral hemorrhage s s evaluation showed no e o aspiration legionella ag negative strep pneumo pending at discharge bcx ngtd at discharge received ivfs and was started on ctx azithromycin with resolution of leukocytosis and rapid return to baseline mental status on the night of the patient was noted to be difficult to arouse after receiving seroquel and ramelteon for insomnia labs and vbg were reassuring and the episode was attributed to medication effect she was again at baseline mental status the following morning although suspicion for infection was relatively low given her initial leukocytosis and rapid improvement on antibiotics or perhaps despite antibiotics she was narrowed to cefpodoxime pcn allergy and prolonged qtc and discharged to complete a 10d course she is being discharged to rehab for and additional support in the setting and acute infections diarrhea c diff ulcerative colitis patient presented with diarrhea in setting of recently diagnosed c diff and concern for po vancomycin non adherence husband was reportedly not giving her the medication 4x d the gi service was consulted and thought a uc flare less likely vancomycin was re initiated with improvement in her diarrhea only loose stools documented daily given likely non adherence her start date for vancomycin should be considered not when originally prescribed with duration of course to be determined by outpatient gi dr but likely weeks after completion of antibiotics through the patient s home prednisone was changed from 6mg alternating with 5mg to 5mg daily for ease of administration per gi of note the patient was often unwilling to take mesalamine didn t appear to have difficulty swallowing capsules but would spit them out this medication was continued on discharge but the patient s outpatient gastroenterologist dr was notified that medication adjustment may be necessary in the outpatient setting leukocytosis wbc on admission improved with fluids resumption of po vancomycin and antibiotics for possible pna vs uti on slightly uptrended to without clear evidence of new infection be secondary to known c diff for which she is being treated wbc on discharge dementia sundowning severe likely fronto temporal dementia at baseline aox1 pleasant conversant but largely nonsensical dependent in most adls per son patient is now back to baseline home memantine was continued although limited data in fronto temporal dementia she frequently tried to get up without nursing assistance and sundowned in the evenings seroquel was trialed initially in combination with ramelteon it caused hypersomnolence given borderline prolonged qtc 450s 460s trazodone 25mg was trialed without effect all efforts should be made to minimize pharmacologic treatments if possible should pharmacologic options be necessary qtc should be monitored closely qtc at discharge was microcytic normocytic anemia hct on admission downtrended to and on discharge ferritin tibc no e o active bleeding further w u was deferred to outpatient providers hypernatremia hypophosphatemia intermittently mildly hypernatremia and hypophosphatemic likely due to poor po intake phos was repleted and po intake encouraged often required prompting to eat with resolution of both concern for inadequate home support the patient s dementia is significant enough that she needs hour help including with most adls there was concern that her husband and primary caregiver may suffer from some dementia himself and is partly unwilling and partly unable to provide necessary around the clock care after a family meeting on the family agree to rehab placement and is considering completion of a application to have long term care as an option afterwards which she will likely need the patient s husband is opposed to this plan but is not the hcp and cannot care for her at home the patient s hcp confirms that she remains full code for now as they discuss as a family transitional f u bcx pending at discharge f u strep pneumo ag pending at discharge check electrolytes including na k phos on monitor qtc if qtc prolonging medications resumed cefpodoxime course outpatient gastroenterologist dr to consider alternatives to mesalamine if patient unwilling to take medications on admission the preadmission medication list is accurate and complete ketoconazole appl tp bid prn rash memantine mg po bid mesalamine mg po in am at night prednisone alternating with mg po daily quetiapine fumarate mg po qhs prn agitation sertraline mg po daily acetaminophen mg po q6h prn pain mild vancomycin oral liquid mg po q6h discharge medications cefpodoxime proxetil mg po q12h rx cefpodoxime mg tablet s by mouth twice a day disp tablet refills prednisone mg po daily trazodone mg po qhs prn insomnia acetaminophen mg po q6h prn pain mild ketoconazole appl tp bid prn rash memantine mg po bid mesalamine mg po in am at night sertraline mg po daily vancomycin oral liquid mg po q6h held quetiapine fumarate mg po qhs prn agitation this medication was held do not restart quetiapine fumarate until told to do so by your primary care doctor discharge disposition extended care facility discharge diagnosis pre syncope clostridium difficile possible uti possible cap discharge condition mental status confused always level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear ms you were admitted to the hospital with confusion and a near fainting episode likely secondary to dehydration in the setting of diarrhea infection was thought unlikely but given some evidence for a urinary tract infection you were started on antibiotics continued at discharge cefpodoxime through given the status of your heart seroquel is likely not the medication for sleep please follow up with your primary care doctor to consider alternatives recognizing that there are no good options available unfortunately you are being discharged to a rehab facility where you will have additional assistance with your medications and self care while you recover your strength with wishes medicine followup instructions

name unit no admission date discharge date date of birth sex m service urology allergies no known allergies adverse drug reactions attending chief complaint renal mass major surgical or invasive procedure left partial nephrectomy history of present illness h o l renal mass now s p robotic l partial really hemi nephrectomy past medical history malignant brain tumor as above colonoscopy for rectal bleeding positive for hemorrhoids social history family history maternal gm with goiter physical exam wdwn nad avss interactive cooperative abdomen soft appropriately tender along incisions incisions otherwise c d i extremities w out edema or pitting and there is no reported calf pain to deep palpation pertinent results 05am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 05am blood glucose urean creat na k cl hco3 angap 05am blood mg rief hospital course partial nephrectomy patient was admitted to urology after undergoing robotic left partial nephrectomy no concerning intraoperative events occurred please see dictated operative note for details the patient received perioperative antibiotic prophylaxis the patient was transferred to the floor from the pacu in stable condition on pod0 pain was well controlled on pca hydrated for urine output 30cc hour and provided with pneumoboots and incentive spirometry for prophylaxis on pod1 the patient ambulated restarted on home medications basic metabolic panel and complete blood count were checked pain control was transitioned from pca to oral analgesics diet was advanced to a clears toast and crackers diet he remained mildly tachycardic in the setting of persistent pain he was 120s post op and 100s on pod1 confirmed multiple times and sinus tachycardia on ekg on pod2 urethral foley catheter were removed without difficulty and diet was advanced as tolerated hr remained in 100s and was down to on pod3 the jp output had remained low and was removed hr remained in the and he felt well ease of ambulation voiding pain controlled the remainder of the hospital course was relatively unremarkable the patient was discharged in stable condition eating well ambulating independently voiding without difficulty and with pain control on oral analgesics on exam incision was clean dry and intact with no evidence of hematoma collection or infection the patient was given explicit instructions to follow up in clinic in approximately four weeks time medications on admission the preadmission medication list is accurate and complete levothyroxine sodium mcg po daily discharge medications levothyroxine sodium mcg po daily acetaminophen mg po q6h docusate sodium mg po bid rx docusate sodium mg tablet s by mouth twice a day disp tablet refills oxycodone immediate release mg po q4h prn pain rx oxycodone mg tablet s by mouth q4hr disp tablet refills discharge disposition home discharge diagnosis renal mass discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions please also refer to the provided handout that details instructions and expectations for your post operative phase as made available by dr office resume your pre admission home medications except as noted always call to inform review and discuss any medication changes and your post operative course with your primary care doctor reduce the strain pressure on your abdomen and incision sites remember to log roll onto your side and then use your hands to push yourself upright while taking advantage of the momentum of putting your legs feet to the ground there may be bandage strips called steristrips which have been applied to reinforce wound closure allow these bandage strips to fall off on their own over time but please remove any remaining gauze dressings within days of discharge you may get the steristrips wet please avoid aspirin or aspirin containing products and supplements that may have blood thinning effects like fish oil vitamin e etc unless you have otherwise been advised this will be noted in your medication reconciliation ibuprofen the ingredient of advil motrin etc may be taken even though you may also be taking tylenol acetaminophen you may alternate these medications for pain control for pain control try tylenol first then ibuprofen and then take the narcotic pain medication as prescribed if additional pain relief is needed ibuprofen should always be taken with food please discontinue taking and notify your doctor should you develop blood in your stool dark tarry stools call your urologist s office to schedule confirm your follow up appointment in weeks and if you have any questions do not eat constipating foods for weeks drink plenty of fluids to keep hydrated no vigorous physical activity or sports for weeks or until otherwise advised light household chores activity and leisurely walking activity is ok and should be continued do not be a couch potato tylenol should be your first line pain medication a narcotic pain medication has been prescribed for breakthrough pain replace the tylenol with this narcotic pain medication if additional pain control is needed max daily tylenol acetaminophen dose is grams from all sources note that narcotic pain medication also contains tylenol do not lift anything heavier than a phone book pounds or drive until you are seen by your urologist in follow up as directed in the handout you may shower normally but do not immerse your incisions or bathe do not drive or drink alcohol while taking narcotics and do not operate dangerous machinery colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication discontinue if loose stool or diarrhea develops colace is a stool softener not a laxative if you have fevers f vomiting or increased redness swelling or discharge from your incision call your doctor or go to the nearest emergency room followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies penicillins gluten attending chief complaint gangrene major surgical or invasive procedure rij central line placed removed bedside debridement by acs picc placed picc removed history of present illness this is a with history notable for hypothyroidism lithium and psoriasis on chronic prednisone mg daily who presented to osh on with abdominal pain vomiting chills found to have shock requiring s hypoxic respiratory failure he was found to have strep pneumo bacteremia the setting of an atrophic spleen his course was complicated by multiorgan failure cerebral edema intra ventricular hemorrhage hypoxic ischemic encephalopathy cva thought to be cardioembolic acute hypoxic respiratory failure stress induced cardiomyopathy afib with rvr ischemic nephropathy requiring crrt on dic c b purpura fulminans with associated digital ischemia and gangrene iso multi pressor requirement he was transferred to the micu on at he was s p trach and peg and was found to have pseudomonal bacteremia and acute exudative hemorrhageic pericardial effusion setting of stemi clean cath detailed foundation course is noted below pulmonary acute respiratory failure tracheostomy peg placed by thoracic surgery at trach collar hrs versus ventilator overnight with trach collar during the day neurologic cerebral edema and intraventricular hemorrhage edema is likely multifactorial given pneumococcal meningitis and prolonged hypoperfusion due to septic shock this was complicated by increased intracranial pressure and hyponatremia which was treated with hypertonic saline drip patient did have an icp monitor placed increased icp resolved and was removed on mr showed extensive anoxic brain injury and infarcts regions consistent with central embolic source and no evidence of herniation bem showed bilateral cortical dysfunction non generalized slow waves no focality due to patient being high risk for seizure activity he was started on prophylactic keppra which is continued throughout the course an mr on showed progression of dwi restriction caudate putamen globus pallidus as well as diffusion restriction multiple areas of cortex as per prior mr that time there is some increase ivh small amount of sch which was new the right frontal region an angiogram on was negative for source of ivh or mycotic aneurysm neurosurgery evaluated and thought the subarachnoid was likely procedural given the poor placement they believe that the ivh was due to coagulopathy of dic a subsequent mr showed resolution of diffusion restriction right resolution of mass effect and stable distribution of parenchymal flair the mr noted new mild ventricular megaly from there was also evidence of hemosiderosis associated with prior ivh and sah eeg continuous video eeg showed bilateral cerebral dysfunction through there is evidence of moderate diffuse encephalopathy however no epileptiform discharges or seizures current plan at target map for cerebral perfusion target platelets greater than hold heparin drip retinal hemorrhages spots corneal exposures evidence of hemorrhage and raw spots on ocular exam with subfoveal hemorrhage versus cherry red spot concerning for cra o during embolic anoxic injury tee deferred due to no probable change management ophthalmology was following they recommended conservative management continued on erythromycin drops and ocular lubrication vascular purpura fulminans dry gangrene patient s ischemic injury is thought to be due to prolonged hypoxemia and vasopressor dependence patient had a skin biopsy on which showed evidence of dic on vascular surgeons recommended no acute surgical intervention and suggested amputations of ischemic limbs once other active issues are stable per vascular note no pulses on doppler of bilateral radial arteries and brachial popliteal arteries family wanted a second opinion and wanted to transfer the patient to for evaluation for possible vascular intervention ivc filter placement unclear indication infectious disease infections strep pneumonia pseudomonas bacteremia stenotrophomonas pneumonia extensive history of antibiotics use and infections patient with persistent tachycardia and recurrent episodes of hypotension and fevers prompting extensive antibiotics use see below for a summary ceftriaxone for strep pneumonia doses of ivig for asplenia increased pressor requirement switched ceftriaxone to plan for weeks per id off pressors intermittent hypotension requiring levophed fever concern for drug fever last day of antibiotics lp tmax started meropenem and cipro again for pseudomonas bacteremia switched to vanco and cipro all lines taken out and replaced switched from cipro to aztreonam vanc was given and discontinued switched from aztreonam to cipro hypotension addition of amikacin for double pseudomonas coverage found to have pericardial effusion s p drainage sputum culture positive for stenotrophomonas thought to be contaminant continued on cipro persistent tachycardia so changed to added fluconazole stopped stopped fluconazole off antibiotics persistent tachycardia up to s infectious workup repeated sputum culture with stenotrophomonas started bactrim dc tabs tid persistent tachycardia for several weeks worsening leukocytosis intermittent hypotension stopped on fluconazole discontinued on given extensive negative workup worsening leukocytosis since on infectious workup sent notable for right lobe consolidation on cxr on sputum culture grew stenotrophomonas pneumonia so started on bactrim ds tabs tid pseudomonas bacteremia cultures have all been negative at until a pseudomonal blood culture which required meropenem on which was transitioned to ciprofloxacin on and then to aztreonam on and then back to ciprofloxacin and patient has now completed his day course of ciprofloxacin patient had all lines exchanged on hd line on the right on patient did have a left ij placed after that stenotrophomonas pneumonia on patient found to have a tracheal aspirate positive for stenotrophomonas which was susceptible to bactrim patient was started on bactrim iv mg per kilo and was continued on his ciprofloxacin stenotrophomonas thought to be a contaminant at that time as noted above sputum culture from grew stenotrophomonas pneumonia so started on bactrim ds tabs tid cardiovascular tachycardia persistent tachycardia sinus with rates s consider to be due to fevers vs pain vs pericarditis vs infections patient status post extensive septic workup including mr brain showing no abscess or empyema lp showing no sign of infection hsv negative cryptococcal antigen negative blood cultures on were negative see above for extensive id workup and antibiotics use ccf was monitoring controlling fever with tylenol and cooling blanket fentanyl as needed for pain as needed fluid boluses continued on colchicine and prednisone for pericarditis hypotension initially with shock requiring pressors from strep pneumo bacteremia eventually weaned off pressors subsequent intermittent hypotension episodes attributed to infections as well as pericardial effusion hypotension now thought to be possibly autonomic the setting of cerebral edema pressures ivh vs adrenal insufficiency has been off pressors for several days pericardial effusion patient found to have pericardial effusion on with normal lvef and normal rv size and function there was a very large circumferential effusion at that time with some ra inversion but no rv collapse ivc was noted to be normal with less than collapsibility the setting of ppv no obvious tamponade was noted however pericardial drain was placed on with cc initial drainage cc the subsequent hours repeat echo showed small residual effusion patient was initially on iv decadron mg every hours was then transitioned to prednisone mg kg for weeks and then on was tapered to mg daily for chronic adrenal insufficiency as well as colchicine makes twice daily for months for post mi postinfectious pericarditis patient is contraindicated to aspirin and nsaids due to hemorrhage and renal dysfunction gastrointestinal nutrition peg tube placed on tube feeds started at continue tube feeds if high residuals then first line is to give reglan rather than stopping tube feeds nephrology due to atn iso septic shock rrt began at outside hospital around transition to ihd on patient did have day of crrt on but resumed ihd on patient has had very high uop from post atn diuresis versus tia versus osmotic diuresis patient receiving d5w for hypernatremia continue to trend renal function replete fluids as needed hematologic functional asplenia patient received ivig from through with repeat igg being normal on igg on was also normal thrombocytopenia and anemia patient with acd elevated ferritin to with an iron of and tibc of patient required multiple transfusions during hospital stay most recently transfuse to hemoglobin less than and platelets less than ctm for active bleeding endocrinology adrenal insufficiency patient has a history of psoriasis on prednisone mg daily patient had an acth stimulation cosyntropin mcg three time point test on with cortisol of and representing inadequate response patient underwent a taper of iv decadron down to mg of prednisone for weeks then to mg of prednisone daily now on mg prednisone daily which started on hypothyroidism this is thought to be lithium induced on patient found to be consistent with sick euthyroid state with a tsh of ft4 f t3 of for this he was kept on l thyroxine to mcg daily plan is to repeat tsh weeks past medical history lithium induced hypothyroidism psoriasis on chronic steroids seasonal affective disorder social history family history no significant immunodeficiency or vascular disease physical exam admission exam vitals reviewed metavision general laying bed chronically ill appearing eyes are open no purposeful movement of the eyes necrotic limbs no movement noted for the extremities multiple pressure ulcers the back of the head back coccyx extremities heent sclera anicteric lungs clear to auscultation bilaterally no wheezes rales rhonchi cv regular rate and rhythm normal s1 s2 no murmurs rubs gallops abd soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext gangrenous limbs up to elbow level for upper extremities and below the knees dopplerable popliteal and brachial arteries discharge exam general laying bed chronically ill appearing eyes are open necrotic limbs no movement noted for the extremities multiple pressure ulcers the back of the head back coccyx extremities able to stick out tongue as yes no response at times heent sclera anicteric lungs clear to auscultation bilaterally no wheezes rales rhonchi cv regular rate and rhythm normal s1 s2 no murmurs rubs gallops abd soft tender to palpation over epigastric region non distended bowel sounds present j tube place ext gangrenous limbs below elbow level for upper extremities and below the knees dopplerable popliteal and brachial arteries pertinent results admission labs 29am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 49pm blood ptt 49pm blood glucose urean creat na k cl hco3 angap 42am blood alt ast alkphos totbili 49pm blood calcium phos mg imaging renal us no hydronephrosis findings suggestive of intrinsic medical renal disease ct head no acute intracranial abnormality identified no evidence of chronic extra axial collection us no evidence of acute deep venous thrombosis the visualized right or left lower extremity veins views of the right and left calf veins however were limited by overlying ulcers tte the left atrium is normal size there is no evidence for an atrial septal defect by 2d color doppler the right atrial pressure could not be estimated there is normal left ventricular wall thickness with a normal cavity size there is mild global left ventricular hypokinesis a left ventricular thrombus mass is not seen but cannot be excluded quantitative biplane left ventricular ejection fraction is the visually estimated left ventricular ejection fraction is left ventricular cardiac index is normal l min m2 there is no resting left ventricular outflow tract gradient mildly dilated right ventricular cavity with normal free wall motion the aortic valve leaflets appear structurally normal there is no aortic valve stenosis there is no aortic regurgitation the mitral leaflets are mildly thickened with no mitral valve prolapse there is trivial mitral regurgitation the tricuspid valve leaflets appear structurally normal there is physiologic tricuspid regurgitation the pulmonary artery systolic pressure could not be estimated there is a trivial pericardial effusion arterial studies findings duplex evaluations performed of the upper extremities the areas that were not wrapped the distal axillary and brachial arteries are patent with triphasic flow and normal velocities impression patent upper extremity arterial system down to the forearm findings duplex evaluations for both lower extremities below the knee cannot be evaluated due to gangrene and dressings the common femoral deep femoral and superficial femoral arteries are patent with triphasic flow and normal velocities impression normal arterial duplex of both lower extremities down to the level of the knee were gangrene is present xray arms the bilateral humeri appear intact with apparent normal mineralization normal alignment and without fracture the there is waisting of the soft tissues left ij catheter is partially imaged and tip appears to project at the superior cavoatrial junction however these views are not optimized for evaluation of catheter tip position multiple lines and tubes overlie the patient obscuring views tracheostomy tube is seen hazy linear opacities at the bilateral lung bases likely represents atelectasis there is a soft tissue swelling surrounding the bilateral elbows and of the bilateral forearms there may be soft tissue defect of the left forearm underlying ulna and radius appear relatively unremarkable no definite fracture there appears to be flexion contractures of the fingers of the bilateral hands there appears to be wasting of the soft tissues no definite fractures identified hands are suboptimally evaluated due to contortion from contractures tte while septic with fungemia normal biventricular cavity sizes with moderate gloaval biventricular hypokinesis no valvular pathology or pathologic flow identified small circumferential pericardial effusion without tamponade physiology us buttocks soft tissue transverse and sagittal images were obtained of the superficial tissues overlying the left ischial tuberosity at the site of known decubitus ulcer there is a defect the skin with fluid pooling at the site of ulceration there is no collection within the subcutaneous tissues or definite evidence for a sinus tract ct abd pelvis lower chest bibasal airspace opacification suspected atelectasis as well as trace pleural effusions appear improved compared to prior retained secretions present the lower lobe bronchi bilaterally trace pericardial effusion is also improved compared to prior abdomen hepatobiliary the liver demonstrates homogenous attenuation throughout there is no evidence of focal lesions there is no evidence of intrahepatic or extrahepatic biliary dilatation the gallbladder is within normal limits pancreas the pancreas has normal attenuation throughout without evidence of focal lesions or pancreatic ductal dilatation there is no peripancreatic stranding spleen small heterogenous residual spleen splenule appears similar to prior adrenals the right and left adrenal glands are normal size and shape urinary the kidneys are of normal and symmetric size with normal nephrogram there is no evidence of focal renal lesions or hydronephrosis there is no perinephric abnormality gastrointestinal the stomach is unremarkable small bowel loops demonstrate normal caliber wall thickness and enhancement throughout the colon and rectum are within normal limits the appendix is normal pelvis distended bladder there is no free fluid the pelvis reproductive organs the prostate is heterogeneous but otherwise unremarkable lymph nodes there is no retroperitoneal or mesenteric lymphadenopathy there is no pelvic or inguinal lymphadenopathy vascular there is no abdominal aortic aneurysm ivc filter situ bones there is no evidence of worrisome osseous lesions or acute fracture soft tissues the abdominal and pelvic wall is within normal limits impression no new acute abdominopelvic process bibasal airspace opacification suspected atelectasis with trace pleural effusions are improved compared to prior small pericardial effusion is also improved compared to prior microbiology am urine source catheter final report urine culture final enterococcus sp cfu ml sensitivities mic expressed mcg ml enterococcus sp ampicillin r linezolid s nitrofurantoin i tetracycline r vancomycin r am sputum source endotracheal final report gram stain final pmns and epithelial cells 100x field per 1000x field gram positive rod s per 1000x field gram positive cocci pairs and singly per 1000x field yeast s smear reviewed results confirmed respiratory culture final moderate growth commensal respiratory flora stenotrophomonas maltophilia moderate growth test result performed by microscan sensitivities mic expressed mcg ml stenotrophomonas maltophilia trimethoprim sulfa s respiratory culture final commensal respiratory flora absent pseudomonas aeruginosa moderate growth piperacillin tazobactam test result performed by yeast sparse growth sensitivities mic expressed mcg ml pseudomonas aeruginosa cefepime i ceftazidime s ciprofloxacin s gentamicin i meropenem i piperacillin tazo s tobramycin s am bronchoalveolar lavage final report gram stain final per 1000x field polymorphonuclear leukocytes per 1000x field gram negative rod s respiratory culture final commensal respiratory flora absent pseudomonas aeruginosa cfu ml piperacillin tazobactam test result performed by stenotrophomonas maltophilia cfu ml sensitivities mic expressed mcg ml pseudomonas aeruginosa stenotrophomonas maltophilia cefepime s ceftazidime s ciprofloxacin s gentamicin i meropenem r piperacillin tazo r tobramycin s trimethoprim sulfa s time taken not noted date time am blood culture final report blood culture routine final parapsilosis consultations with id are recommended for all blood cultures positive for staphylococcus aureus yeast or other fungi yeast susceptibility fluconazole mic of mcg ml susceptible results were read after hours of incubation test result performed by sensititre aerobic bottle gram stain final reported to and read back by on yeast s pm sputum source endotracheal final report gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s respiratory culture final sparse growth commensal respiratory flora pseudomonas aeruginosa moderate growth pseudomonas aeruginosa moderate growth morphology piperacillin tazobactam test result performed by sensitivities mic expressed mcg ml pseudomonas aeruginosa pseudomonas aeruginosa cefepime s i ceftazidime i s ciprofloxacin s s gentamicin s i meropenem r i piperacillin tazo s s tobramycin s s pm urine source catheter final report urine culture final pseudomonas aeruginosa cfu ml piperacillin tazobactam test result performed by viridans streptococci cfu ml sensitivities mic expressed mcg ml pseudomonas aeruginosa cefepime s ceftazidime s ciprofloxacin i gentamicin i meropenem i piperacillin tazo s tobramycin s pm stool consistency not applicable source stool final report c difficile pcr final negative reference range negative the c difficile pcr is highly sensitive for toxigenic strains of c difficile and detects both c difficile infection cdi and asymptomatic carriage a negative c diff pcr test indicates a low likelihood of cdi or carriage pm sputum source endotracheal gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s per 1000x field budding yeast respiratory culture preliminary commensal respiratory flora absent pseudomonas aeruginosa moderate growth piperacillin tazobactam test result performed by ceftolozane tazobactam ceftazidime avibactam susceptibility requested per yeast sparse growth pseudomonas aeruginosa sparse growth morphology sensitivities mic expressed mcg ml pseudomonas aeruginosa pseudomonas aeruginosa cefepime i s ceftazidime i s ciprofloxacin s s gentamicin i s meropenem i s piperacillin tazo r s tobramycin s s pm blood culture source line picc blood culture routine preliminary yeast presumptively not c albicans consultations with id are recommended for all blood cultures positive for staphylococcus aureus yeast or other fungi aerobic bottle gram stain final yeast s reported to and read back by on pm urine source final report urine culture final enterococcus sp cfu ml yeast cfu ml sensitivities mic expressed mcg ml enterococcus sp ampicillin r linezolid s nitrofurantoin i tetracycline r vancomycin r discharge pertinent labs 05am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 05am blood ptt 05am blood glucose urean creat na k cl hco3 angap 47am blood k 22am blood alt ast alkphos totbili 15am blood caltibc ferritn trf 59am blood triglyc 10am blood triglyc 11pm blood triglyc 49am blood triglyc 23am blood tsh 08am blood tsh 23am blood free t4 53am blood 25vitd 39pm blood anca negative b 20pm blood po2 pco2 ph caltco2 base xs 20pm blood lactate is a h o hypothyroidism lithium who presents as a transfer from for evaluation of necrotic limbs by vascular surgery patient initially presented to a hospital w generalized illness nausea and vomiting and was found to have septic shock streptococcus the setting of atrophic spleen unknown at time of presentation ct scan from with normal size spleen w course complicated by respiratory failure renal failure hypoxic brain injury intracerebral hemorrhage myocardial infarction w resultant pericardial effusion s p pericardial drain dic purpura fulminans resulting gangrene of all limbs his course at was complicated by enterococcus uti vap and fungemia and endocrine abnormalities he was briefly transferred to the floor anticipation of possible discharge to however he became febrile tachycardic and hypotensive on concerning for recurring sepsis and was transferred back to for further care current active issues infection recurrent vap d t multiple strains of mdr psa sputum cultures growing strains pseudomonas aeruginosa sensitive to ciprofloxacin given high risk of developing resistances to fluoroquinolones infectious disease consulted recommended ciprofloxacin iv and cefepime iv prolonged infusion over hours hours between end of one infusion and beginning of next day end date if still with respiratory compromise can extend this to days fungemia presumably recurrent c parapsilosas unknown source ct abdomen pelvis with contrast negative blood cultures on growing c parapsilosas sensitive to fluconazole septic this setting during which tte showed depressed global biventricular function given poor po absorption unclear if this was consistently treated optimally switched iv to po and error missed one day blood cultures negative until growing awaiting speciation decompensated from this with tachycardia fever and soft bp switched to iv micafungin on removed for line holiday currently with peripheral per id recs continue micafungin mg iv daily x14 days from picc removal day day follow up speciation from sputum culture note if fungemia recurs recommend tee to evaluate for endocarditis considered during current presentation though the setting of likely incomplete inadequate treatment with poor azole absorption through gi tract will consider this same original infection bacteruria of unclear significance held on treating enterococcus most recent ucx exam felt more c w abdominal as opposed to suprapubic pain no e o inflammation on ua like previously treated uti and no fungemia and mdr pseudomonal pneumonia to explain fever and improvement with treatment of above wound care necrotic limbs dry gangrene patient s ischemic injuries occurred the setting of shock with s dic w purpura fulminans the patient s family desired a second opinion from and this was the primary reason for transfer to he was seen by the vascular surgery plastic surgery teams at who felt there was no need for urgent intervention the patient should follow up with vascular surgery dr surgery dr two weeks after discharge pt also has several decubitus ulcers right and left gluteal area that required debridement from wound nurse while inpatient pt has been getting wound care daily pain palliative care consulted currently difficult to assess pain given patient is minimally interactive can follow few commands but this waxes and wanes pain manifested as agitation tachycardia also able to show us his tongue at times for yes and no answers location limbs intermittently abdomen currently maintained on methadone and iv dilaudid can consider iv methadone if suspicious for poor po absorption iso intermittent vomiting which is his baseline acute on chronic respiratory failure s p trach placement he had a tracheostomy placed at he was treated for stenotrophomonas pna found on tracheal aspirate with tmp smx then levofloxacin due to hyperkalemia for a urrently being treated for vap multidrug resistant strains of pseudomonas please see above currently on trach collar but has required vent for mucous plugging intermittently nausea vomiting with bilious projective vomiting occurring once every few days to once a day gi consulted and concern for stress gastritis and ulcerations gi loosened external bumper of his peg to avoid burring of internal bumper given it was found that connection between peg tube and feeding pump was short and was tugging at peg site recommended for lansoprazole to 30mg bid and giving enough slack to connection between feeding pump and peg to avid tugging of peg also recommended hyoscyamine improved cramping abdominal pain and metoclopramide pt has also been receiving iv ativan infrequently if vomiting patient should have tube feeds and all medications given through j part of gj tube giving meds through g part of gj tube can exacerbated vomiting encephalopathy neurologic status ich the etiology of his brain injury was felt to be the setting of multifactorial pneumococcal meningitis and prolonged hypoperfusion w resultant cerebral hypoxia and ich the setting of septic shock multiple mris at showed extensive anoxic brain injury on admission here neurology was consulted for prognostication ultimately neurology felt that he would likely suffer permanent deficits however they were not able to prognosticate further than that he did begin to become responsive and was able to follow some simple commands he was given keppra for seizure prophylaxis ot s s speech and swallow consult for valve endocrinopathies iatrogenic adrenal insufficiency hypothyroidism hypercalcemia of immobility endocrinology was consulted and recommended prednisone mg daily unless stress dose steroids necessitated fludricortisone mg levothyroxine mcg anemia of inflammation iron studies keeping with inflammation he was transfused for hgb he did not have evidence of active bleeding left filamentary keratitis xerophthalmia patient was evaluated by ophthalmology and diagnosed with filamentary keratitis he was started on vigamox antibiotics qid and completed the course of antibiotics he should continue lubricating eye drops per ophthalmology he should follow up with ophthalmology two weeks after discharge artificial tears tid artificial tears gel severe protein calorie malnutrition continue tube feeds of note found to be hypertg given hypertg and nausea vomiting lipase normal pt was switched to lower osm tube feeds and tolerating it better resolved issues from extended hospitalization recurrent hyperkalemia hypernatremia records rrt began at around transitioned to ihd on at he was eventually liberated from dialysis his creatinine then settled out the mid range on admission to his creatinine rose from on arrival to where it plateaued his hour urine collection with creatinine showed creatinine clearance of only around indicating that his gfr is lower than would be predicted based on his serum creatinine likely from lower creatinine generation he was continually non oliguric w urine showing granular debris and cast fragments indicating tubular injury which rose suspicion for ischemic hemodynamic injury of unclear precipitant additionally he had low urine specific gravity and isosthenuria suggesting a concentrating defect and it was considered that he was not regulating his urine volume well as such he was given aggressive ivf prn to maintain his volume status a broad work up was sent to investigate this aso anca upep which was largely unrevealing notably had positive aso which raised possibility of post infectious gn but as complement levels were normal it was felt that this positive result was not clearly pathogenic ultimately his resolved and cr normalized to the setting of his he had persistent hypernatremia hyperkalemia which were managed with free water repletion and management of his adrenal insufficiency and initiation of fludrocortisone primary adrenal insufficiency patient does not have history of chronic prednisone use prior to initial illness as noted documentation patient had an acth stimulation cosyntropin mcg three time point test on with cortisol of and representing inadequate response he underwent a taper of iv dexamethasone down to mg of prednisone for weeks then to mg of prednisone daily now on mg prednisone daily which started on repeat stim test showed ongoing insufficiency thus patient was transitioned to prednisone 10mg po qd per the recommendations of endocrinology and mg daily at times of stress retinal hemorrhages filamentous keratitis inferior corneal ulcer at the patient had evidence of hemorrhage on ocular exam with subfoveal hemorrhage versus cherry red spot concerning for crao during embolic anoxic injury he was seen by ophthalmology for continued evaluation who were concerned about the extensive eye dryness and recommended follow up two weeks following discharge resistant enterococcus uti noted on urine culture based on sensitivities he was treated with linezolid sinus tachycardia heart rates persistently usually the range despite management of multiple infections pain fluid status patient received lr day for management of insensible losses that could be contributing to tachycardia to good effect type ii nstemi mild troponin elevation with t wave inversions setting of mucus plugging trop peaked at mb was flat patient was not anticoagulated nutrition pej tube placed on at given recurrent aspiration events he underwent advancement to gj on the nutrition service followed him closely for evaluation and support patient should have tube feeds and all medications given through j part of gj tube giving meds through g part of gj tube can exacerbated vomiting hypothyroidism known chronic problem thought to be lithium induced on patient found to be consistent with sick euthyroid state with a tsh of ft4 f t3 of for this he was kept on l thyroxine mcg daily he was evaluated by endocrine who felt that it is very likely that he is not absorbing oral levothyroxine specially the setting of high tf residual volume he was given iv bolus of 150mcg iv lt4 at 3pm on and then transitioned to iv lt4 for continued management he was switched back to oral levothyroxine at a high dose mcg to overcome interference by tube feeds hypercalcemia the endocrine service was consulted for management he was given iv zoledronic acid 3mg given on with some improvement calcium endocrine felt that this was a pth independent process with high degree of bone resorption based on very elevated ctx most likely due to immobilization given the clinical circumstances there was no evidence of fhh post rhabdo delayed hypercalcemia would not respond to bisphosphonate or have elevated ctx malignancy granulomatous disease or lithium induced hypercalcemia pthrp is and his d is he was continued on vitamin d therapy transitional issues continue keppra months per neurology should continue to be seen by therapy per neuro his prognosis is guarded unclear how much neurologic function he will recover vascular surgery follow up should be done weeks after hospital discharge surgery should follow weeks after hospital discharge opthalmology should follow weeks after hospital discharge recheck tsh on 200mcg levothyroxine weeks repeat tte weeks last tte setting of septic shock with improved function on bedside exam end date for abx ciprofloxacin and cefepime for vap micafungin for fungemia picc to be placed on or after wound care daily debridement prn follow up speciation for blood culture follow up blood cultures ngtd hold on treating enterococcus most recent ucx for now exam felt more c w abdominal as opposed to suprapubic pain no e o inflammation on ua like previously treated uti and no if fungemia recurs recommend tee to evaluate for endocarditis considered during current presentation though the setting of likely incomplete inadequate treatment with poor azole absorption through gi tract will consider this same original infxn should need additional records from fax to pt was icu on g62 there for months qtc daily given pt on several qtc prolonging medications can space out less frequently after completion of ciprofloxacin access piv contact rabbi code full confirmed medications on admission the preadmission medication list is accurate and complete prednisone mg po daily discharge medications acetaminophen mg po q6h prn pain mild artificial tears gel drop both eyes artificial tears preserv free drop both eyes tid bisacodyl mg pr constipation third line cefepime g iv q8h chlorhexidine gluconate oral rinse ml oral bid ciprofloxacin mg iv q8h docusate sodium mg po bid fludrocortisone acetate mg po daily gabapentin mg po guaifenesin ml po q6h prn mucous secretions heparin unit sc bid hydromorphone dilaudid mg iv q3h prn pain severe hyoscyamine mg po qid ipratropium albuterol neb neb neb q6h prn wheezing ipratropium albuterol neb neb neb q6h sob wheezing lansoprazole oral disintegrating tab mg po bid levetiracetam mg po q12h levothyroxine sodium mcg po daily methadone mg po q8h pain metoclopramide mg po tid micafungin mg iv q24h multivitamins w minerals ml po daily polyethylene glycol g po daily senna mg po bid vitamin d unit po 1x week we prednisone mg po daily discharge disposition extended care facility discharge diagnosis four extremity dry gangrene fungemia adrenal insufficiency mild pericardial effusion hypernatremia mdr pseudomonas pna discharge condition mental status minimally interactive level of consciousness lethargic but arousable activity status bedbound discharge instructions dear mr and family you were admitted to for vascular surgery evaluation while the hospital your course was complicated by several infections including pneumonia and fungus the blood you will be discharged to where you will receive on going care to treat you infection as well as rehabilitation to make you stronger details regarding the specifics of the infectious are outlined below sincerely your team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies gluten ceftazidime attending chief complaint four limb ischemia major surgical or invasive procedure four limb amputation on history of present illness mr is a year old man with history of hypothyroidism and psoriasis on chronic prednisone 5mg daily who has had a long complicated course resulting in multiorgan failure hypoxic ischemic encephalopathy is now non verbal diffuse bacteremia stress induced cardiomyopathy and four limb ischemia after demarcation the decision was made to pursue a four limb amputation in conjunction with orthopedics on briefly the patient initially presented to an osh in on with abdominal pain vomiting chills he was found to have septic shock bacteremia with s pneumopniae requiring vasopressors and developed hypoxic respiratory failure he developed hypoxic ischemic encephalopathy with intra ventricular hemorrhage and cva thought to be cardioembolic he also had acute renal failure requiring crrt part of his care was the where he received a trach and peg that was later converted to a gj by he was transferred from to and he was in our hospital during the period where he was also found to have multiudrug resistant pseudomonas pneumonia depressed ef heart failure fungemia presumably recurrent c parapsilosas s p treatment with iv micafungin his four limb ischemia was thought to be in the setting of shock with s dic w purpura fulminans he was discharged to and he has remained there up until today of note recently he had his gj tube exchanged by on and converted to a mic gj due to malfunctioning he has been on lovenox for dvts which we have instructed to stop on he now presents as a direct admit from in anticipation of his surgery he is non verbal and the history is acquired from chart review past medical history lithium induced hypothyroidism psoriasis on chronic steroids seasonal affective disorder social history family history no significant immunodeficiency or vascular disease physical exam discharge physical exam gen resting in bed thin trach in place appears uncomfortable heent nc at moist mucous membranes no lesions neck trach in place jvp does not appear elevated cv regular rate normal rhythm no murmurs appreciated resp clear to auscultation bilaterally gi soft gj tube in place msk all limbs wrapped from amputations but incisions are cdi with slight granulation tissue on rue and lle rle incision cdi except for packing of previously slightly purulent area skin no rashes on exposed skin scars on lle neuro psych alert answers yes no at times to questions opens his eyes and tracks perrl pertinent results discharge labs 24am wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 04am neuts bands monos eos metas myelos nrbc absneut abslymp absmono abseos absbaso 24am ptt 24am glucose urean creat na k cl hco3 angap 24am calcium phos mg pertinent interval labs 32pm 19pm 32pm hapto 08am hapto 46am caltibc ferritn trf 19pm t4 free t4 15am tsh 00am tsh 19pm prolact 19pm t4 free t4 admission labs 03pm wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 46am neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 55am ptt 03pm glucose urean creat na k cl hco3 angap 19pm alt ast alkphos totbili 03pm calcium phos mg microbiology data culture routine final parapsilosis susceptibility fluconazole mic of mcg ml susceptible results were read after hours of incubation test result performed by sensititre urine culture pseudomonas aeruginosa cfu ml of two colonial morphologies pseudomonas aeruginosa cefepime s ceftazidime s ciprofloxacin s gentamicin s meropenem s piperacillin tazo s tobramycin s csf studies enterovirus culture negative gram stain final fluid culture ngtd cryptococcal antigen negative cryptococcal antigen negative wound gram stain final per 1000x field polymorphonuclear leukocytes no microorganisms seen wound culture preliminary mixed bacterial flora pseudomonas aeruginosa rare growth of two colonial morphologies anaerobic culture preliminary no anaerobes cultures x2 pnd urine culture final gram positive coccus cocci cfu ml am urine source final report urine culture final enterococcus sp cfu ml sensitivities mic expressed in mcg ml enterococcus sp ampicillin r linezolid s nitrofurantoin i tetracycline r vancomycin r am swab source r leg gram stain final per 1000x field polymorphonuclear leukocytes per 1000x field gram negative rod s per 1000x field gram positive cocci in pairs wound culture preliminary mixed bacterial flora this culture contains mixed bacterial types so an abbreviated workup is performed any growth of p aeruginosa s aureus and beta hemolytic streptococci will be reported if these bacteria are not reported they are not present in this culture anaerobic culture preliminary pm sputum source endotracheal final report gram stain final pmns and epithelial cells 100x field gram stain indicates extensive contamination with upper respiratory secretions bacterial culture results are invalid please submit another specimen respiratory culture final test cancelled patient credited c difficile pcr final negative reference range negative the c difficile pcr is highly sensitive for toxigenic strains of c difficile and detects both c difficile infection cdi and asymptomatic carriage a negative c diff pcr test indicates a low likelihood of cdi or carriage radiology data cxr new focal consolidation in the left lower lung consistent with infection small left pleural effusion interval placement of right picc line terminating in the right atrium ct head increased in ventricular system which may indicate development of communicating hydrocephalus since the prior study although temporal horn dilatation which has increased in particular may be associated with temporal lobe atrophy degree of atrophy is not obviously increased mri head no evidence of acute infarction hemorrhage or mass generalized atrophy evolution of the multiple infarctions demonstrated in small amount of residual old products in the fourth ventricle brief hospital course year old man with pmhx of lithium induced hypothyroidism psoriasis on chronic steroids who had a prolonged and complicated series of hospitalization from to for sepsis with dic complicated by limb ischemia from pressors and dic as well as multiple other complications during which endocrinology was consulted for hypercalcemia hypothyroidism and adrenal insufficiency he has been re admitted for a planned limb amputation which took place on the patient has now been transferred to medicine for further management of fungemia and pseudomonas uti since being on the medicine service he had a seizure as well as cultures positive for fungemia and subsequent hap history of strep bacteremia with limb ischemia s p amputation the patient developed ischemic limbs secondary to purpura fulminans as a sequelae of strep pneumo bacteremia and pressor shock the patient was admitted for and underwent a four limb amputation on the patient had epidural and supraclavicular blocks performed and was continued on a ketamine gtt as well as dilaudid iv and oxycodone prn the pain service was consulted and per their recommendations the patient s gabapentin and methadone were increased and he was continued on oxycodone to mg q4h prn and hydromorphone to mg q2h prn for severe pain per plastics and vascular surgery the patient s ketamine was discontinued on and the epidural was removed on the patient was transferred out of the icu without issue hospital acquired pneumonia versus recurrent uti in the setting of up trending leukocytosis low grade fevers and softer pressures a cxr was done on showing a new lll opacity c f infection pna given the patient s prolonged hospitalization he was diagnosed with hap and his ciprofloxacin was discontinued and he was broadened to zosyn of note the patient developed eosinophilia and seizure while on a cephalosporin which is why zosyn was chosen he was continued on vancomycin a ucx was drawn at the same time and returned as vre just after discharge although it is not completely clear patient actually had a uti rather than just colonization particularly since his wbcs improved with addition of zosyn it was thought prudent to change vancomycin to linezolid so the discharging attending called over to inform the receiving attending of the above and to give a detailed warm handoff intermittent hypotension primary adrenal insufficiency the patient was intermittently hypotensive during his hospitalization when trying to taper his steroids his hypotension is most likely multifactorial but largely due to his primary adrenal insufficiency his lactate was normal when checked during hypotensive episodes the patient received multiple ivf boluses of note his prior testing showed l renin h and cortisol l and acth high which was consistent with primary adrenal insufficiency adrenal antibodies were negative endocrinology was consulted and managed tapering of his steroids which were complicated by hypotension when decreased too rapidly discharged on hydrocortisone 20mg iv q8hrs for days end then switch to 15mg po qam and then 5mg po q2 3pm resume fludrocortisone on leukocytosis the patient initially had a leukocytosis to when he presented on this trended up to and began to resolved to on with the treatment of his bloodstream infection wound dehiscence and pseudomonas uti as described below on his wbc count increased from and was down trending until when it again spiked to at this time a cxr was done showing a new pneumonia as described as above his c diff was negative the remainder of his infections were treated as described elsewhere bloodstream infection the patient s course was complicated by cultures growing he was initially treated with micafungin them escalated to amphotericin before being tailored to fluconazole based on sensitivities infectious disease signed off and recommended fluconazole iv for weeks picc line exchanged by on ophthalmology was consulted and found no evidence of endophthalmitis a lp was done see below which was unremarkable and showed no signs of infection lle wound dehiscence the patient was noted to have a wound dehiscence by the surgical teams wound cultures grew pseudomonas as well as cons and enterococcus the patient was initially stared on vancomycin and ciprofloxacin for a planned week course the cipro was changed to zosyn for coverage of hap as described above wound care plastics and orthopedics continued to follow the patient while inpatient given some mild purulent discharge at a stitch on rle a swab cx was performed on the results of which are still pending but anticipate covered by addition of zosyn to vanc complicated uti the patient had a ua done which was positive for nitrites and moderate bacteria his culture grew pan sensitive pseudomonas aeruginosa on id was consulted and recommended a week course of antibiotics for complicated uti the patient completed a week course of ciprofloxacin a complicated uti first time generalized seizure communicating hydrocephalus the patient had a had a first time generalized seizure on which resolved with 2mg iv ativan subsequently started on keppra mg bid had imaging done which was concerning for communicating hydrocephalus he underwent an lp which showed wbc elevated protein possibly due to the residual intraventricular products seen on mri csf gram stain enterovirus and cryptococcus antigen was negative csf cultures were negative eeg was without evidence of seizure activity he had no further clinical or electrographic seizures while inpatient neurology was consulted and signed off on with their final recommendations being to continue keppra malnutrition gj tube dysfunction tube feeds the patient s gj tube came out on and was replaced by on on the was a foamy appearance to gj tube drainage so ordered showing coiling of the gj tube into the stomach was re consulted and patient underwent another tube replacement on nutrition was following for tf recommendations and he was switched to nepro tube feeds given hyperkalemia anemia while inpatient the patient had hemoglobin s that are widely variant with his hgb usually being in the range on his hgb dropped from to with an appropriate response to 1u prbcs there was no sign of bleeding and his labs were not consistent with hemolysis eosinophilia drug induced resolved the patient was noted to have an eosinophilia which was thought to be from ceftazidime this resolved after switching to ciprofloxacin chronic pain post operative pain the chronic pain service was consulted and recommended continuing hydromorphone mg iv q2h prn for breakthrough pain dressing changes the also recommended continuing methadone mg po ng q8h pain and oxycodone liquid 15mg prn he was continued on gabapentin 600mg tid and standing acetaminophen 650mg q6h hypothyroidism the patient has a history of hypothyroidism with negative tpo ab and tg ab on prior admission the patient required iv and high dose levothyroxine administration to overcome tube feeds but he has been weaned to 100mcg at rehab tfts obtained this admission show t4 free t4 confirming adequate replacement as an outpatient he is now on continuous tf endocrinology was consulted and stated that if tfs are switched to cycled his iv levothyroxine can be converted to po levothyroxine their dosing recommendations lt4 75mcg iv of oral dose if on continuous tf which impacts absorption when he is switched to bolus tf he can be converted to po lt4 mcg daily with holding tube feeds for hours prior hour after tf minutes spent on patient care and coordination on day of discharge transitional issues antibiotics vancomycin for hap and wound dehiscence end zosyn for wound dehiscence and hap end routine ekg monitoring for qt interval while on methadone patient was noted to have metas on his differential consider following with hematology and potential bone marrow biopsy consider switching tfs to cycled if tfs are switched to cycled his iv levothyroxine can be converted to po levothyroxine their dosing recommendations lt4 75mcg iv of oral dose if on continuous tf which impacts absorption when he is switched to bolus tf he can be converted to po lt4 mcg daily with holding tube feeds for hours prior hour after tf please check tfts on per endocrine wean pain medications as able steroid taper per endocrine recommendations discharged on hydrocortisone 20mg iv q8hrs for days end then switch to 15mg po qam and then 5mg po q2 3pm resume fludrocortisone on follow up cbc with differential f u wound swab from and adjust antibiotics pending results would need to also cover hap as above monitor na which has been almost borderline elevated and consider more free water or volume as discussed on phone by discharging attending please change vancomycin to linezolid to cover for possibility of uti which would also cover hap pcp was unknown to patient s wife but may be known to father in law please assess who is his pcp and please pass on this discharge summary to that person should follow up with orthopedics plastics endocrinology infectious disease code full this patient was prescribed or continued on an opioid pain medication at the time of discharge please see the attached medication list for details as part of our safe opioid prescribing process all patients are provided with an opioid risks and treatment resource education sheet and encouraged to discuss this therapy with their outpatient providers to determine if opioid pain medication is still indicated medications on admission the preadmission medication list is accurate and complete artificial tears preserv free drop both eyes tid bisacodyl mg pr qhs prn constipation third line chlorhexidine gluconate oral rinse ml oral bid guaifenesin ml po q6h prn mucous secretions hyoscyamine mg po bid levothyroxine sodium mcg po daily methadone mg po q8h pain metoclopramide mg po q12h polyethylene glycol g po daily prn constipation third line acetaminophen liquid mg po ng q6h prn pain mild fever amantadine syrup mg po ng bid collagenase ointment appl tp daily cranberry mg j tube daily enoxaparin sodium mg sc daily hydromorphone dilaudid mg iv q3h prn pain severe gabapentin mg j tube qhs hydrocortisone mg po bid hydroxypropyl meth ophth each eye nightly lactinex lactobacillus acidoph l bulgar million cell oral daily miconazole powder appl tp bid omeprazole mg po daily polyvinyl alcohol povidone ophthalmic eye tid sodium hypochlorite topical daily discharge medications cyclobenzaprine mg po bid prn muscle spasm erythromycin ophth oint in both eyes qid glutamine gm po daily hydrocortisone na succ mg iv q8h lansoprazole oral disintegrating tab mg po daily levetiracetam oral solution mg po q12h levothyroxine sodium mcg iv daily oxycodone liquid mg po q4h prn pain moderate piperacillin tazobactam g iv q8h duration days vancomycin mg iv q 24h duration days methadone mg po q8h pain consider prescribing naloxone at discharge acetaminophen liquid mg po q6h prn pain mild fever amantadine syrup mg po bid artificial tears preserv free drop both eyes tid bisacodyl mg pr qhs prn constipation third line chlorhexidine gluconate oral rinse ml oral bid collagenase ointment appl tp daily cranberry mg j tube daily enoxaparin sodium mg sc daily gabapentin mg j tube qhs guaifenesin ml po q6h prn mucous secretions hydromorphone dilaudid mg iv q3h prn pain severe hydroxypropyl meth ophth each eye nightly hyoscyamine mg po bid lactinex lactobacillus acidoph l bulgar million cell oral daily metoclopramide mg po q12h miconazole powder appl tp bid polyethylene glycol g po daily prn constipation third line polyvinyl alcohol povidone ophthalmic eye tid sodium hypochlorite topical daily held levothyroxine sodium mcg po daily this medication was held do not restart levothyroxine sodium until your tube feeds are switched to cycled discharge disposition extended care facility discharge diagnosis dry gangrene of all limbs complicated acquired pneumonia stream infection generalized tonic clonic seizures discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions discharge instructions dear mr it was a pleasure caring for you at why was i in the hospital you were admitted to the hospital for an amputation of your arms and legs because they were not getting enough what happened to me in the hospital you had an amputation of your arms and legs you developed a fungal stream infection which was treated with antifungal medications at the recommendations of our infectious disease team you developed a urinary tract infection which was treated with antibiotic medications at the recommendations of our infectious disease team you had a seizure the neurology team was consulted and you were started on anti seizure medications you had a lumbar puncture to look for an infection of your spinal cord or brain this did not show any evidence of infection you developed a pneumonia which was treated with antibiotic medications at the recommendations of our infectious disease team our endocrinology team was consulted to mange your steroids and thyroid medications what should i do after i leave the hospital please take your medications and go to your follow up appointments as described in this discharge summary if you experience any of the danger signs listed below please call your primary care doctor or go to the emergency department immediately we wish you the best sincerely your team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies aloe apple egg attending major surgical or invasive procedure none attach pertinent results admission labs 45pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct unable to 45pm blood neuts lymphs 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 45pm blood albumin calcium phos mg 51pm blood po2 pco2 ph caltco2 base xs comment green top 51pm blood lactate 10pm blood lactate 52am blood lactate 37am blood lactate pertinent labs 07am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 10am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 07am blood ptt 10am blood ptt 28am blood alt ast alkphos totbili 41am blood alt ast alkphos totbili 21am blood alt ast alkphos totbili 45pm blood ctropnt 07am blood caltibc ferritn trf 07am blood 07am blood ret aut abs ret 12am blood hbsag neg hbsab neg hbcab neg hav ab neg 12am blood hcv ab neg 38pm blood lactate 46am blood lactate micro pm blood culture final report blood culture routine final final sensitivities sensitivities mic expressed in mcg ml amikacin s cefepime s ceftazidime s ceftriaxone s ciprofloxacin r gentamicin r meropenem s piperacillin tazo s tobramycin r trimethoprim sulfa s pm urine final report urine culture final no growth pm blood culture source venipuncture final report blood culture routine final no growth imaging cta chest study date of nonspecific cm nodular left upper lobe opacity which may represent pneumonia recommend follow up ct chest in months to assess for resolution pulmonary nodule not excluded malpositioned foley catheter with balloon in the base of the penis moderate amount stool in the distal sigmoid colon rectosigmoid equivocal associated mild wall thickening possible early stercoral colitis chronic appearing left hip dislocation with adjacent soft tissue thickening adjacent joint effusion not excluded kub there are diffusely air filled dilated loops of large bowel involving the right and transverse colon with moderate descending and sigmoid colonic stool burden no dilated loops of small bowel visualized there is no evidence of free intraperitoneal air right lower abdominal wall battery pack and single spinal stimulator lead noted overlying the right lower abdomen and pelvis surgical clips in the right upper quadrant again noted at least moderate bilateral hip degenerative changes incompletely assessed impression no evidence of pneumoperitoneum nonobstructive bowel gas pattern with moderate stool burden ruq us liver the left lobe of the liver is not adequately visualized due to overlying bowel gas otherwise the hepatic parenchyma appears within normal limits the contour of the liver is smooth there is no focal liver mass the main portal vein is patent with hepatopetal flow there is no ascites bile ducts there is no intrahepatic biliary dilation chd mm gallbladder the gallbladder is not definitively visualized however there is a rounded structure in the area of the gallbladder fossa measuring x x cm which may represent a contracted gallbladder impression no evidence of intrahepatic or extrahepatic biliary dilatation likely contracted gallbladder splenomegaly discharge labs no labs collected 21am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 21am blood plt 21am blood glucose urean creat na k cl hco3 angap 21am blood alt ast alkphos totbili 21am blood calcium phos mg discharge exam vitals temp po bp l lying hr rr o2 sat o2 delivery ra heent sclera anicteric mmm oropharynx clear lungs clear to auscultation bilaterally no wheezes rales or rhonchi cv regular rate and rhythm normal s1 s2 no murmurs rubs or gallops abdomen soft non tender mildly distended bowel sounds present no rebound tenderness or guarding ext warm with pulses trace pitting edema in the feet bilaterally boots on skin no rashes or lesions neuro responds appropriately to questions and follows commands unable to move bilaterally labs reviewed in brief hospital course summary mr is a man with a history of advanced secondary progressive multiple sclerosis with cognitive decline who presented from his group home with sepsis and lactic acidosis requiring brief micu admission 24h and found to have providencia stuartii bacteremia on presentation to the ed his ua was consistent with possible uti but his urine cultures remained without growth during his hospital course he had a ct torso that showed a possible l lingular pneumonia and he was briefly on ctx azithro in the setting of new oxygen requirement but he was quickly weaned off of oxygen and did not have other symptoms of pneumonia uri and it was stopped additionally ct torso showed possible stercoral colitis and he was briefly on flagyl his hospital course was complicated by constipation requiring manual disimpaction in the ed after which he remained constipated and his bowel regimen was escalated until he had several large bowel movements after days without any on presentation to the ed he had hematuria from a traumatic foley in his urethera that was placed at the group home the foley was removed and he was voiding well with a condom catheter although retaining 500cc before urinating which per the patient and his family is what he usually uses for treatment of his providencia stuartii bacteremia he underwent guided r picc placement and id was consulted and he was started on cefepime to complete a week course from his last negative blood culture with a plan to switch to ertapenem at discharge for ease of dosing he was noted to have transaminitis on and ruq us showed no evidence of structural causes and his transaminitis was thought to be secondary to cephalosporins and he was switched to meropenem on with improvement of his transaminitis he remained hemodynamically stable and afebrile on iv antibiotics with negative surveillance cultures and with resolution of his thrombocytopenia which was thought to be secondary to sepsis and he was discharged back to his group home on ertapenem to complete his course of iv antibiotics last day transitional issues he will need to continue iv antibiotics with ertapenem 1g q24 hours until last day okay to remove picc line after course of iv antibiotics completed he is due for a refill of his baclofen pump on confirmed with group home that they will be able to refill it there when he gets back have physician at home check cbc and lfts in week to make sure that his thrombocytopenia and transaminitis have resolved please follow up with his neurologist about management of his possible early urinary retention neurogenic bladder please avoid foley as he is voiding well with a condom catheter but he usually doesn t void until he is retaining 600ccs please order a repeat ct chest in months to evaluate for resolution of l lingular opacity his ct imaging demonstrated left hip fluid collection joint effusion ortho reviewed the imaging and it appears chronic since based on prior xray he is not immune to hep b surface ab neg but has an egg allergy sneezing if allergy not severe he should receive the hep b vaccine acute issues fever sepsis uti l lingula pneumonia provide bacteremia patient was febrile to at outpatient facility and was on presentation to the ed his ua was grossly positive with prior dysuria c f uti in the setting of recent foley possibly placed on for possible chronic urinary retention although usually urinates well with a condom cath of note his urine culture from the er without growth ct chest concerning for possible l lingula pneumonia but patient clinically without symptoms of pneumonia and stopped ctx azithro as penumonia unlikely bcx from growing providencia which is usually from a urinary source but of note all his urine cultures remained negative id was consulted and recommended a week course of abx from first negative culture with cefepime mg iv q12h while inpatient and plan to discharge on ertapenem g iv daily for ease of once daily dosing however due to elevated transaminases thought to be due to cephalosporins he was changed from cefepime to meropenem with improvement in his transaminitis he remained afebrile and hemodynamically stable with negative blood cultures on iv antibiotics and was discharged back to his group home on ertapenem g q24h through elevated lfts transaminitis drug induced liver injury elevated alt ast with normal alk phos and bili c w hepatocellular pattern notably lfts were normal upon presentation hepatitis panel with hep b non immune but otherwise negative ruqus with poorly visualized left liver lobe but otherwise normal hepatic parenchyma given no structural deficits transaminitis thought to be due to cephalosporins and he was switched to meropenem on with gradual improvement in his lfts urinary retention hematuria traumatic foley placement he has a questionable history of urinary retention and it is unclear why he had a foley on presentation to the ed as he is usually able to void okay with a condom catheter per the patient and his family but notes from the osh state it was placed for urinary retention on ct a p in the ed his foley was misplaced in his urethra and likely was the cause of his hematuria the foley was replaced in the ed and removed in the icu and a condom cath was placed we paged urology several times about if he could be straight cathed if necessary or if he would require another foley if he was retaining urine but we did not get a response his hematuria resolved and he was voiding well with the condom cath and did not require straight cath of note he was retaining cc on bladder scan before voiding stercoral colitis constipation ct a p was concerning for stercoral colitis and he was manually disimpacted in ed in one of the notes from the group home there was mention of ulcerative colitis but per patient and family there is no diagnosis of uc and he is not on treatment for it he has chronic constipation at baseline and his bowel regimen was escalated including miralax senna lactulose bisacodyl and multiple enemas until he finally had several large bowel movements on the day without any he developed nausea and abdominal cramping from his constipation and kub at that time showed moderate stool burden without evidence of ileus obstruction or perforation multiple sclerosis baclofen pump patient has a history of advanced progressive ms with cognitive decline and has a baclofen pump he stated that his pump needs to be refilled soon and anesthesia was consulted for baclofen pump interrogation on 299mcg day and he is due for a refill on before discharge we confirmed with his group home that they will be able to refill his pump when he returns dislocated hip w effusion ct a p demonstrated chronic appearing left hip dislocation with complex fluid collection c f hematoma vs infection within the hip joint without evidence of bone erosion ortho reviewed the images and thought it was most likely chronic dislocation since in a patient that is mostly bedbound we had low clinical suspicion for a septic joint as he did not have any pain and remained stable on antibiotics for treatment of his bacteremia thrombocytopenia resolved patient presented with thrombocytopenia plt at lowest and initially it was unclear if it was chronic but was not present as of and his labs were negative for hemolylsis or dic with treatment of his sepsis bacteremia his platelet count gradually recovered and was normal on day of discharge and was thought to be secondary to sepsis lactic acidosis resolved he presented with lactic acidosis in the ed likely iso sepsis as above he was initially fluid responsive to 2l ivf but his lactic acidosis uptrended upon arrival to the icu likely in the setting of insufficient fluid resuscitation his lactic acidosis then resolved on after adequate fluid resuscitation with an additional 2l of lr chronic issues vitamin d deficiency osteoporosis he was continued on his home vitamin d and calcium code status full confirmed molst in chart contact hcp mother medications on admission the preadmission medication list is accurate and complete calcium carbonate mg po bid docusate sodium mg po bid multivitamins tab po bid senna mg po daily naproxen mg po q12h prn pain mild acetaminophen mg pr q6h prn pain mild fever acetaminophen mg po q6h prn pain mild fever clotrimazole cream appl tp bid prn rash sodium fluoride dental gel appl tp bid loratadine mg po daily prn allergy vitamin d unit po daily lioresal baclofen mcg ml injection daily polyethylene glycol g po daily prn constipation first line discharge medications ertapenem sodium g iv 1x duration dose acetaminophen mg pr q6h prn pain mild fever acetaminophen mg po q6h prn pain mild fever calcium carbonate mg po bid clotrimazole cream appl tp bid prn rash docusate sodium mg po bid lioresal baclofen mcg ml injection daily loratadine mg po daily prn allergy multivitamins tab po bid naproxen mg po q12h prn pain mild polyethylene glycol g po daily prn constipation first line senna mg po daily sodium fluoride dental gel appl tp bid vitamin d unit po daily discharge disposition extended care facility discharge diagnosis primary diagnosis providencia bacteremia sepsis secondary diagnosis fever l lingular opacity without evidence of pneumonia transaminitis drug induced liver injury hematuria secondary to traumatic foley placement possible stercoral colitis constipation multiple sclerosis with baclofen pump chronically dislocated left hip with effusion thrombocytopenia resolved lactic acidosis resolved vitamin d deficiency 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 privilege taking care of you at why was i admitted to the hospital you were admitted to the hospital because you had a fever degrees what happened while i was in the hospital you were found to have an infection in your blood and were started on iv antibiotics the foley catheter in you bladder wasn t in the correct place and it was removed and you were voiding okay without it you were not having bowel movements and you finally had a bowel movement after lots of medications what should i do after i leave the hospital please continue to take all your medications and follow up with your doctors at your appointments we wish you all the best sincerely your care team followup instructions

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 s p left total hip replacement via anterior approach with dr history of present illness y o female with history of left hip osteoarthritis who has failed conservative measures and has elected to undergo definite surgical management past medical history copd bipolar s p club foot repair 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 clean dry and intact scant serosanguinous drainage thigh full but soft no calf tenderness strength silt nvi distally toes warm pertinent results lle ultrasound no evidence of deep venous thrombosis in the left lower extremity veins chest x ray in comparison with the study of the cardiomediastinal silhouette is stable and there is no evidence of vascular congestion there are small bilateral pleural effusions with compressive basilar atelectasis bilaterally no evidence of acute focal pneumonia 10am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 20am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 24am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 10am blood plt 20am blood plt 24am blood plt 10am blood glucose urean creat na k cl hco3 angap 20am blood glucose urean creat na k cl hco3 angap brief hospital course the patient was admitted to the orthopedic surgery service and was taken to the operating room for above described procedure please see separately dictated operative report for details the surgery was uncomplicated and the patient tolerated the procedure well patient received perioperative iv antibiotics postoperative course was remarkable for the following on pod the patient was sent for a chest x ray to rule out pneumonia due to a low oxygen saturation and increasing white count chest x ray showed basilar atelectasis bilaterally and her incentive spirometer was encouraged she was also sent for a left lower extremity ultrasound to rule out a blood clot due to left thigh swelling the ultrasound was negative for a blood clot 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 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 at all times for weeks ms is discharged to home with services in stable condition medications on admission bupropion sustained release mg po bid duloxetine mg po daily gabapentin mg po bid ibuprofen mg po bid prn pain moderate risperidone mg po qam risperidone mg po qpm acetaminophen mg po q8h prn pain mild calcium d calcium carbonate vitamin d3 mg 500mg unit oral bid womens daily formula m u l t i v i t i r o n f a c a l cium mins br multivitamin ca iron minerals br mv mn iron fa ca carb vit k mg oral daily discharge medications docusate sodium mg po bid stop taking if having loose stools enoxaparin sodium mg sc daily start first dose next routine administration time oxycodone immediate release mg po q4h prn pain moderate senna mg po bid stop taking if having loose stools acetaminophen mg po q8h bupropion sustained release mg po bid calcium d calcium carbonate vitamin d3 mg 500mg unit oral bid duloxetine mg po daily gabapentin mg po bid risperidone mg po qam risperidone mg po qpm womens daily formula m u l t i v i t i r o n f a c a l cium mins br multivitamin ca iron minerals br mv mn iron fa ca carb vit k mg oral daily held ibuprofen mg po bid prn pain moderate this medication was held do not restart ibuprofen until you complete your course of lovenox 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 independent 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 lovenox for four weeks 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 wound checks activity weight bearing as tolerated with walker or crutches at all times for six weeks 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 mobilize frequently assistive device x weeks i e two crutches or walker 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 orthopaedics allergies no known allergies adverse drug reactions attending chief complaint periprosthetic fracture of the left hip major surgical or invasive procedure revision left total hip arthroplasty history of present illness year old female s p l tha anterior approach with increased pain difficulty with ambulation noted to have periprosthetic fracture of the left hip on hip x ray admitted for surgical repair on past medical history copd bipolar s p club foot repair social history family history non contributory physical exam exam on discharge vitals avss general well appearing breathing comfortably on 2lnc msk left lower extremity abduction pillow in place hip incision from l tha with area of eschar at middle aspect thigh soft compressible lateral dressing clean dry and intact fires sensation intact to light touch in spn dpn tibial saphenous sural distributions foot wwp pertinent results 10am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 20am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 20am blood glucose urean creat na k cl hco3 angap 00pm blood albumin calcium phos mg iron brief hospital course the patient was admitted to the orthopedic surgery service from clinic after she was found to have a periprosthetic fracture of her left hip she was admitted for pre operative clearance she 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 the patient received unit of blood for a low hematocrit the patient responded appropriately she is asymptomatic and hemodynamically stable on discharge we recommend obtaining a follow up hematocrit this week 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 surgical dressing will remain on until pod after surgery the foley was removed and the patient was voiding independently thereafter 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 partial weight bearing on the operative extremity with no hip bridging no repetitive resistant hip flexion walker or two crutches at all times for weeks ms is discharged to rehab in stable condition medications on admission the preadmission medication list is accurate and complete gabapentin mg po bid risperidone mg po qam risperidone mg po qpm duloxetine mg po qam bupropion mg po bid ibuprofen mg po bid prn pain mild acetaminophen mg po q8h prn pain mild calcium with vitamin d calcium carbonate vitamin d3 mg 500mg unit oral bid womens daily formula m u l t i v i t i r o n f a c a l cium mins br multivitamin ca iron minerals br mv mn iron fa ca carb vit k mg oral daily discharge medications bisacodyl mg po pr daily prn constipation docusate sodium mg po bid enoxaparin sodium mg sc daily duration weeks start today first dose next routine administration time oxycodone immediate release mg po q4h prn pain rx oxycodone mg tablet s by mouth every four hours disp tablet refills pantoprazole mg po q24h senna mg po bid gabapentin mg po bid acetaminophen mg po q8h prn pain mild aluminum magnesium hydrox simethicone ml po q6h prn dyspepsia bupropion mg po bid calcium with vitamin d calcium carbonate vitamin d3 mg 500mg unit oral bid duloxetine mg po qam risperidone mg po qam risperidone mg po qpm womens daily formula m u l t i v i t i r o n f a c a l cium mins br multivitamin ca iron minerals br mv mn iron fa ca carb vit k mg oral daily held ibuprofen mg po bid prn pain mild this medication was held do not restart ibuprofen until you follow up with dr discharge disposition extended care facility discharge diagnosis periprosthetic fracture of the left hip 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 lovenox for four weeks to help prevent deep vein thrombosis blood clots if you were taking aspirin prior to your surgery you should hold this medication during your one month course of anticoagulation medication 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 partial weight bear with walker or crutches at all times posterior precautions abduction pillow while sleeping no hip bridging no repetitive resistant hip flexion no strenuous exercise or heavy lifting until follow up appointment mobilize frequently physical therapy partial weight bear posterior precautions abuction pillow while sleeping assistive device for ambulation i e crutches walker no hip bridging and no repetitive resistant hip flexion 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 staple removal and replace with steri strips on pod14 at followup instructions

name unit no admission date discharge date date of birth sex f service surgery allergies penicillins attending chief complaint liposarcoma major surgical or invasive procedure left colectomy radical excision of rp liposarcoma history of present illness presented on for evaluation of a new retroperitoneal mass occurring in close proximity to the distal sigmoid colon and involving the psoas and colonic mesentery she had related a history of undergoing surgery for a large retroperitoneal lesion in the year records indicate that ct in showed a large mass within the left hemiabdomen extending from the pancreatic tail and left kidney to the deep pelvis involving the left iliac artery mri tumor nearly surrounding the aorta and left iliac vessels with compression and near obliteration of the vascular signal within the left iliac vein apparently she received weeks of radiation therapy she then underwent en bloc resection large tumor adherent to the left iliac veins with a markedly displaced left ureter and marked involvement of the sigmoid colon mesentery a transverse colon to sigmoid anastomosis was described apparently because of the compression of the iliac vein an ivc filter was placed at the time of surgery pathology showed grade well differentiated liposarcoma with no areas of dedifferentiation involving the pericolonic fat and mesovarium but it did not invade the muscularis of the bowel wall or the fallopian tube or ovary the tumor is stated to abut the inked surfaces in multiple areas no microscopic margins were provided recently ct scan of showed a soft tissue mass within the mesocolon invading into the mesentery measuring about cm there are also multiple t2 hypointense enhancing soft tissue nodules in the same region which most likely invade the anterolateral aspect of the left psoas muscle there is some soft tissue stranding around the celiac axis and in association with the left renal vessels and anterior perirenal fascia which is of uncertain significance nothing is seen in the region of the left iliac vessels the mri was limited in scope because of the presence of extensive spinal hardware core biopsy of her left retroperitoneal mass in showed recurrent liposarcoma she presents today for resection past medical history liposarcoma l abdomen s p radiation resection t2n0 right breast cancer s p partial mastectomy radiation multifocal invasive lobular carcinoma a fib with thrombotic events lvh mild pulmonary htn h o pulmonary embolisms superficial phlebitis dm2 glaucoma hld htn renal failure gerd djd low back psh sarcoma excision spinal fusion r breast partial mastectomy and slnb l knee arthroscopy rotator cuff repairs l2 s1 spinal fusion physical exam discharge exam t98 hr99 bp130 rr18 ra gen nad aox3 cv regular rate irregular rhythm s1 s2 pulm ctab gi soft nt minimally distended wound midline incision staples clean dry intact minimal staple line erythema no drainage no induration ext wwp no cce brief hospital course was admitted on for surgical treatment of her left retroperitoneal mass she was on afib before surgery she underwent left colectomy and radical excision of rp liposarcoma her ebl was cc and she received crystalloid and albumin in her early postoperatory to maintain normal blood pressure and adequate urine output the patient was kept npo had a foley and a right ij line she had a pca for analgesia she had daily chem10 and her electrolytes were repleted on her hct dropped to and her hr maintained in the 140s she received one unit of rbc during the following days her hr was very labile around 120s at rest and up to 160s with minimal activity on she was passing flatus and had one bowel movement her home atenolol and lasix were started cardiology was consulted and recommended stopping atenolol starting metoprolol and increasing the dose while assessing her response she also had persistent loose bowel movements from to c diff and stool studies were negative she received mg of loperamide x2 with significant improvement in her diarrhea she was bridged from lovenox to warfarin on after receiving doses of warfarin her inr was warfarin was held and inr was monitored daily being at discharge at the time of discharge the patient was doing well tolerating a regular diet having normal bowel movements therapeutic on warfarin and her heart rate was controlled she received discharge teaching and follow up instructions medications on admission the preadmission medication list is accurate and complete atenolol mg po daily brimonidine tartrate ophth drop both eyes q8h citalopram mg po daily furosemide mg po daily latanoprost ophth soln drop both eyes qhs metformin glucophage mg po bid simvastatin mg po qpm trazodone mg po qhs prn insomnia warfarin mg po daily16 enoxaparin sodium mg sc bid discharge medications metoprolol succinate xl mg po bid rx metoprolol succinate mg tablet s by mouth twice per day disp tablet refills warfarin mg po daily16 brimonidine tartrate ophth drop both eyes q8h citalopram mg po daily furosemide mg po daily latanoprost ophth soln drop both eyes qhs metformin glucophage mg po bid simvastatin mg po qpm trazodone mg po qhs prn insomnia held atenolol mg po daily this medication was held do not restart atenolol until you discuss with your cardiologist discharge disposition home with service facility discharge diagnosis liposarcoma discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear you were admitted to and underwent surgery to remove your left colon and an abdominal tumor you have been recovering well and the health of your skin graft is improving the following is a summary of discharge instructions medications please resume all home medications unless specifically advised not to take a particular medication please take any new medications as prescribed please take all pain medications as prescribed as needed you may not drive or operate heavy machinery while taking narcotic pain medications you may also take acetaminophen tylenol as directed but do not exceed mg in one day wound care monitor the wounds for signs of infection including redness that is spreading or increased drainge from wounds please call dr if you experience any of these symptoms your staples will be removed at your next appointment activity no strenuous activity until cleared by dr no showering until cleared by dr sponge baths only call the office immediately if you have any of the following signs of infection fever with chills increased redness swelling warmth or tenderness at the surgical site or unusual drainage from the incision s a large amount of bleeding from the incision fever greater than of severe pain not relieved by your medication return to the er if if you are vomiting and cannot keep in fluids or your medications if you have shaking chills fever greater than f degrees or c degrees increased redness swelling or discharge from incision chest pain shortness of breath or anything else that is troubling you any serious change in your symptoms or any new symptoms that concern you followup instructions

name unit no admission date discharge date date of birth sex f service surgery allergies penicillins hydromorphone morphine allopurinol dilaudid attending chief complaint with a complex pmhx presenting with stage iiib recurrent retroperitoneal sarcoma major surgical or invasive procedure s p ex lap debulking of recurrent liposarcoma of abdomen gastric repair history of present illness pt has a complex past medical history including recurrent liposarcoma summarized below in pt had a retroperitoneal liposarcoma resection w en block sigmoid resection at the pt received radiotherapy for weeks prior to operation pathology report at that time grade well differentiated liposarcoma no areas of dedifferentiation no information provided on margins in a colonoscopy was performed which found a new submucosal mass in the mid sigmoid colon with normal overlying mucosa was found imaging found a cm lobulated mass pt had mri of the abdomen which showed a 3cm soft tissue mass with multiple t2 hypointense nodules in the are of the anterolateral left psoas and adjacent mesentery core needle biopsy showed a low grade liposarcoma which was mdm and cdk positive dr a left colectomy and resection of the underlying superficial psoas the left colon showed a multifocal well differentiated liposarcoma sclerosing subtype low grade involving the colonic wall and extending to the radial resection margin the largest tumor mass measured cm and six lymph nodes were normal an anterior abdominal wall nodule also showed recurrent low grade liposarcoma with necrosis extending to the specimen margin ct abd pelvis shows a fatty and soft tissue lesion in the gastro hepatic region concerning for recurrent liposarcoma with other unchanged soft tissue lesions near the iliac bone left common iliac artery nodule in pancreatic tail patient was not operated on at that time because she was in severe chf and pending a mitral valve replacement pt was noticed to have lesion that increased in size on ct imaging mri had concerning findings for recurrence of liposarcoma with increased size of a soft tissue and fatty mass in the area of the lesser sac with additional masses in the left lower abdominal mesentery and near the tail of the pancreas she was planned for an abdominal debulking procedure with dr past medical history liposarcoma l abdomen s p radiation resection t2n0 right breast cancer s p partial mastectomy radiation multifocal invasive lobular carcinoma a fib with thrombotic events lvh mild pulmonary htn h o pulmonary embolisms superficial phlebitis dm2 glaucoma hld htn renal failure gerd djd low back psh sarcoma excision spinal fusion r breast partial mastectomy and slnb l knee arthroscopy rotator cuff repairs l2 s1 spinal fusion social history family history mother breast ca age father melanoma aunts 3x breast cancer ages maternal uncle liver cancer no family members with sarcoma physical exam gen alert awake calm cooperative pleasant cv rrr normal s1 s2 no rubs murmurs gallops resp ctab with no wheezing crackles rales rhonchi abd dressing over ex laparotomy scar soft no masses no distention pertinent results 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood ptt 00am blood glucose urean creat na k cl hco3 angap 00am blood calcium phos mg 45am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 45am blood glucose urean creat na k cl hco3 angap 45am blood calcium phos mg brief hospital course ms presented to holding at on for an ex lap to debulk a recurrent liposarcoma and gastric repair she tolerated the procedure well without complications please see operative note for further details after a brief and uneventful stay in the pacu the patient was transferred to the floor for further post operative management neuro pain was well controlled on tylenol toradol dilaudid pca later tramadol cv the patient remained stable from a cardiovascular standpoint vital signs were routinely monitored pulm the patient remained stable from a pulmonary standpoint oxygen saturation was routinely monitored had good pulmonary toileting as early ambulation and incentive spirometry were encouraged throughout hospitalization gi the patient was initially kept npo after the procedure and was managed with an ngt and ivfs ngt was pulled and the pt tolerated po clear liquid diet without n v abdominal pain the patient was later advanced to and tolerated a regular diet at time of discharge with return of bowel function patient s intake and output were closely monitored gu the patient had a foley catheter that was removed prior to discharge urine output was monitored as indicated at time of discharge the patient was voiding without difficulty id the patient was closely monitored for signs and symptoms of infection and fever heme the patient had blood and electrolyte levels checked routinely during their hospital course to monitor for signs of bleeding and metabolic disturbance the patient received subcutaneous heparin inr monitoring with lovenox bridging for warfarin and dyne boots as well as encouragement to get up and ambulate as early as possible on the patient was discharged to home at discharge she was tolerating a regular diet passing flatus voiding and ambulating independently she will follow up in the clinic in week with dr and to keep her dressing on until then this information was communicated to the patient directly prior to discharge medications on admission the preadmission medication list is accurate and complete warfarin mg po daily citalopram mg po daily exemestane mg po daily furosemide mg po daily latanoprost ophth soln drop both eyes qhs metoprolol succinate xl mg po daily brimonidine ophthalmic eye bid potassium chloride meq po daily simvastatin mg po qpm trazodone mg po qhs discharge medications docusate sodium mg po bid omeprazole mg po daily duration days rx omeprazole mg capsule s by mouth once a day disp capsule refills tramadol mg po q4h prn pain moderate rx tramadol mg tablet s by mouth every six hours disp tablet refills warfarin mg po once duration dose brimonidine ophthalmic eye bid citalopram mg po daily exemestane mg po daily furosemide mg po daily latanoprost ophth soln drop both eyes qhs metoprolol succinate xl mg po daily potassium chloride meq po daily simvastatin mg po qpm trazodone mg po qhs discharge disposition home discharge diagnosis recurrent stage iiib recurrent retroperitoneal liposarcoma discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted to on for an exploratory laparotomy with excision of cm retrogastric mass iiib recurrent retroperitoneal sarcoma and suture repair of gastric laceration you tolerated the procedure well without complications and were able to advance and tolerate a regular diet with return of your bowel and urinary function after discharge from the hospital please refrain from participating in any heavy lifting greater than pounds attempt to keep your dressing clean and dry and monitor for warning signs such as warmth redness discharge swelling fevers please call the office or the nearest emergency room if you experience pain with eating or drinking using the restroom bleeding persistent nausea and vomiting and or abdominal swelling please do not ibuprofen following you surgery for the next month due to your gastric surgical repair it is important that you receive a check of your inr level tomorrow as an outpaitent and to keep your dressing intact until you see dr in week 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 none attach pertinent results dc exam vs temp bp l lying hr rr o2 sat o2 delivery ra general pleasant fatigued appearing man in no distress lying in bed heent anicteric perll op clear mmm cardiac rrr no murmurs lung appears in no respiratory distress clear to auscultation bilaterally with no focal crackles or wheeze abd soft non tender non distended positive bowel sounds ext warm well perfused no lower extremity edema neuro a ox3 good attention and linear thought gross strength and sensation intact able to state backwards skin no significant rashes 42pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 45pm blood ptt 42pm blood glucose urean creat na k cl hco3 angap 42pm blood calcium phos mg 45pm blood ferritn cxr impression opacification in the right lower lobe adjacent to the right heart border and retrocardiac opacification best appreciated on lateral film concerning for a right lower lobe pneumonia brief hospital course mr is a male with mds and prostate cancer localized prostate cancer on lupron with questionable rib metastasis htn parkinsons who presented with fever and pneumonia acute bacterial pneumonia dx based on fever cxr findings viral vs bacterial but treated for bacterial no recent antbx no recent hospitalizations flu neg legionella negative he responded to ctx azithro and was transitioned to complete course of cefpodoxime azitho through and respectively anemia in malignancy thrombocytopenia likely due to underlying mds and now worsening with bone marrow involvement of prostate cancer he responded appropriately to his blood transfusion and has outpatient follow up thereafter prostate cancer now with bone marrow involvement with recent bone marrow biopsy follow up with dr back pain want to consider repeat bone scan as outpatient mds not on mds directed therapy continue to monitor urinary symptoms continue home tamsulosin hypertension he was hypertensive to sbp 180s asymptomatic he was initiated back on his hctz which he had stopped he was subsequently found to have orthostasis with sbp decrease to 150s standing asymptomatic he may have dysautonomia as a result of his parkinsons he was instructed to monitor his bp at home and follow up with his pcp and neurologist to see if he requires further medication adjustment disease continue sinemet bid hypothyroidism he states he no longer takes levothyroxine medications on admission the preadmission medication list is accurate and complete tamsulosin mg po qhs carbidopa levodopa tab po bid loratadine mg po daily acetaminophen mg po q6h prn pain mild fever discharge medications azithromycin mg po daily duration doses take on and rx azithromycin mg tablet s by mouth once a day disp tablet refills cefpodoxime proxetil mg po q12h start on and take through rx cefpodoxime mg tablet s by mouth twice a day disp tablet refills hydrochlorothiazide mg po daily rx hydrochlorothiazide mg tablet s by mouth once a day disp tablet refills tramadol mg po bid severe back pain rx tramadol mg tablet s by mouth twice a day disp tablet refills acetaminophen mg po q6h prn pain mild fever rx acetaminophen mg tablet s by mouth four times a day disp tablet refills carbidopa levodopa tab po bid loratadine mg po daily tamsulosin mg po qhs discharge disposition home discharge diagnosis bacterial pneumonia chronic anemia mds ca discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted with fever and fatigue you were found to have pneumonia and started on antibiotics you will need to complete a course of treatment as prescribed you were also given a blood transfusion due to your chronic anemia please follow up with your hematologist for ongoing care you were also seen by your prostate oncologist you will follow up with her to monitor response to treatment finally you were restarted on hydrochlorothiazide for high blood pressure in the hospital please check your blood pressure at home when you are feeling better and bring your readings to your next doctor appointment we have provided information to establish a new pcp at at please call to schedule an appointment with a new doctor followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies lisinopril attending chief complaint bloody stool major surgical or invasive procedure egd history of present illness mr is an yo man with a history of gerd oa on celecoxib anemia who presents to the ed after having had dark bms for the past couple of days he has noted some feelings of heartburn at home and says that he has missed doses of his omeprazole over the past couple weeks he denies dizziness light headedness chest pain palpitations n v diarrhea constipation he also suffered a mechanical fall weeks ago no fracture present on xray mri preformed on read pending in the ed his initial vs were ra his exam was notable for guaiac positive stool he was given pantoprazole 40mg iv and 1l ns he was typed and crossed but not transfused a bladder scan was also done for concern for urinary retention and he had 66cc in his bladder on arrival to the floor patient reports that overall he is feeling well he is having pain in his l elbow because of recent fall and some mild abdominal discomfort review of systems per hpi past medical history gerd knee osteoarthritis aaa bph spinal stenosis hx of pancytopenia per pcp mds hernia insomnia lower extremity edema wearing compression stockings social history family history coronary artery disease physical exam admission physical exam vs 5po general nad appears stated age well nourished heent atraumatic normocephalic eomi perrl mmm heart rrr no murmurs rubs gallops lungs ctab no wheezes ronchi rales abdomen nabs mildly tender to palpation in llq no rebound or guarding extremities wwp pitting edema of bilateral lower extremities with l slightly greater than r contusion on l elbow with intact rom but tenderness to palpation neuro a ox3 moving all extremities with purpose cn ii xii intact able to say months of the year backwards skin warm and well perfused no excoriations or lesions no rashes discharge physical exam vs t97 ra general in no acute distress sitting comfortably in his chair heent at nc anicteric sclera pink conjunctiva neck nontender supple neck no lad no jvd heart rrr normal s1 s2 no murmurs gallops or rubs lungs ctab no wheezes rales rhonchi breathing comfortably without use of accessory muscles abdomen nondistended active bowel sounds nontender to palpation no rebound guarding no hepatosplenomegaly extremities bilateral lower extremity edema extending to knee tender to touch bilaterally stockings in place pulses dp pulses bilaterally neuro cn ii xii grossly intact skin large ecchymoses present in left inner elbow and tracking down to left wrist some ecchymoses also present on right arm warm and well perfused no excoriations or lesions no rashes pertinent results admission labs 04pm urine blood neg nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg 15pm ptt 24pm glucose urea n creat sodium potassium chloride total co2 anion gap 24pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 24pm neuts monos eos basos im absneut abslymp absmono abseos absbaso pertinent labs 57pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 15am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 15am blood plt 57pm blood plt 15am blood glucose urean creat na k cl hco3 angap discharge labs 10am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 10am blood plt microbiology urine culture final no growth pertinent imaging ble dvt us no evidence of deep venous thrombosis in the lower extremity veins egd normal mucosa in the esophagus medium hiatal hernia normal mucosa in the whole stomach biopsy normal mucosa in the duodenum small erosion noted in the hiatal hernia sac otherwise normal egd to third part of the duodenum brief hospital course mr is an yo man with a history of gerd duodenal ulcer years ago and anemia baseline hgb who presents with melena acute issues melena due to hiatal hernia erosion patient s most recent egd was which was normal he had another egd on this admission which revealed a small erosion at a hiatal hernia narrowing since patient s home medications celecoxib and aspirin increase his risk of bleeding they were held during the hospital course and patient was started on iv pantoprazole 40mg twice daily his hemoglobin remained stable for hospital stay without need for transfusion patient was transitioned to and discharged with oral pantoprazole twice daily his hemoglobin and vitals remained stable and he no longer had melena he was scheduled for outpatient colonoscopy anemia patient has baseline anemia hgb with macrocytic component folate and vitamin b12 were within normal limits l upper arm pain patient had a recent fall on when he fell while using his walker x ray showed no evidence of fracture but mri revealed full length full width triceps tendon rupture patient pain was controlled on tylenol physical therapy and occupational therapy saw patient did not recommend a splint regarding rehabilitation exercises they recommended follow up with orthopedic surgery bilateral lower extremity edema patient has baseline lower extremity edema with no history of cardiac disease likely secondary to venous insufficiency he wears compression stockings on presentation he had significant tenderness in his lower legs so bilateral ultrasound of the lower extremities was done negative for dvt chronic issues gerd patient home omeprazole was switched to pantoprazole twice daily he was discharged with changed medication bph maintained on home tamsulosin chronic pain from lumbar and cervical spondylosis and osteoarthritis maintained on home gabapentin and lidocaine patches celecoxib was held in the setting of gi bleed his pain can be managed with tylenol transitional issues new medication pantoprazole 40mg twice daily celecoxib osteoarthritis was discontinued in setting of bleed pain can be controlled with tylenol outpatient colonoscopy on followup with orthopedic surgery on for triceps tendon rupture contact code full presumed medications on admission the preadmission medication list is accurate and complete gabapentin mg po tid lidocaine patch ptch td qam celecoxib mg oral daily omeprazole mg po daily aspirin mg po daily tamsulosin mg po qhs discharge medications acetaminophen mg po tid multivitamins tab po daily pantoprazole mg po q12h calcium carbonate mg po qam gabapentin mg po tid lidocaine patch ptch td qam tamsulosin mg po qhs vitamin d unit po daily held aspirin mg po daily this medication was held do not restart aspirin until your doctor tells you to since it can cause bleeding discharge disposition extended care facility discharge diagnosis primary diagnosis upper gi bleed secondary to hiatal hernia erosion secondary diagnosis left elbow pain gastroesophageal reflux disease bilateral lower extremity edema likely venous stasis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr why were you here you were admitted for blood in your stool what was done for you in the hospital the gastrointestinal team did a procedure and used a camera to look for the source of your bleeding they found an area of erosion at the top of your stomach hiatal hernia you did not require any blood transfusions what should you do once you get home you were prescribed a new medication pantoprazole which you will need to take twice daily to help prevent bleeding you will have a colonoscopy on please follow up with the clinic for your left arm pain what can you do to help prevent future ulcers avoid taking nsaids avoid eating spicy or acidic foods such as tomatoes and orange juice quit smoking if you smoke limit your alcohol intake it was a pleasure to take care of you your team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies lisinopril desipramine verapamil attending chief complaint agitation major surgical or invasive procedure none history of present illness mr is a male with history of bipolar disease depression disease vascular dementia bilateral knee replacements peripheral neuropathy diabetes ckd episodes of falls with head injury bipolar disorder heart block status post ppm dvt on coumadin who presents with wife and son with complaint of weeks of worsening mental status anxiety and depression of note he was referred to the ed from his psychiatrist for concern of worsening mood due to organic etiology they state that he does have baseline dementia but this is been particularly bad over the past weeks he has been very anxious and depressed he has been complaining of pain in the lower extremities particularly around the left heel where he has an ulcer he denies fevers or chills he has not been complaining of any chest pain shortness of breath abdominal pain vomiting diarrhea urinary symptoms he has been eating and drinking well his blood sugars have been well controlled at home no recent falls he uses a walker but is very limited in his ability to ambulate he also uses a transfer chair at home he does have some visiting nurse resources wife states that she spoke with his psychiatrist today who sent him to the emergency department of note mr follows with psychiatry here for post concussive syndrome as well as dementia related to and vascular dementia he last saw psych on where his psychiatrist mentioned that the patient has had a turbulent course over the past year characterized by episodes of falls with head injury mr has been confined to a wheelchair for some time and has been cared for by his extended family his recent course has been complicated by periods of delirium impaired cognitive status his baseline mental status is noted to be the following subdued sad faced not overtly tearful complaining of depression speech is reduced in rate productivity there is a paucity of thought no evidence of spontaneous tearfulness during mental status evaluation he appears to be somewhat disoriented not fully oriented in all spheres past medical history bipolar disorder disease vascular dementia social history family history noncontributory physical exam admission exam general elderly male lying in bed no acute distress heent perrl eomi mmm no regional lymphadenopathy no erythema of the oropharynx neck no regional lymphadenopathy or thyromegaly lungs clear to auscultation bilaterally cv rrr s1 s2 present no murmurs rubs gallops no jvd gi bs present soft nontender nondistended no hepatomegaly ext no peripheral edema heel of the left lower extremity has a well healed 1x1 cm ulcer without any evidence of erythema purulence or drainage neuro patient states that he is at he is not alert to day of the week month or year he states that he lives with his parents cranial nerves ii through xii intact strength out of in the upper extremities b l strength in the lower extremities b l discharge exam vitals per omr general elderly male lying in bed no acute distress heent pupils small reactive to light lungs clear to auscultation bilaterally cv rrr s1 s2 present no murmurs rubs gallops no jvd gi bs present soft nontender nondistended ext no peripheral edema heel of the left lower extremity has a well healed 1x1 cm ulcer without any evidence of erythema purulence or drainage pulses present by palpation bilaterally neuro patient states that he is at he is not alert to day of the week month or year he states that he lives with his parents cranial nerves ii through xii intact strength out of in the upper extremities b l strength in the lower extremities b l pertinent results labs 55am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 55am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 15am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 02am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 59am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 55am blood glucose urean creat na k cl hco3 angap 55am blood glucose urean creat na k cl hco3 angap 48am blood glucose urean creat na k cl hco3 angap 15am blood glucose urean creat na k cl hco3 angap 02am blood glucose urean creat na k cl hco3 angap 55am blood alt ast alkphos totbili 48am blood calcium phos mg 02am blood calcium phos mg 59am blood glucose urean creat na k cl hco3 angap 03pm blood glucose urean creat na k cl hco3 angap 30am blood glucose urean creat na k cl hco3 angap inr 20pm blood ptt 15am blood ptt 02am blood ptt 30am blood ptt 59am blood ptt 30am blood ptt brief hospital course assessment plan mr is a male with history of bipolar disorder depression peripheral neuropathy diabetes ckd who presented with weeks of worsening mental status anxiety and depression and was found to have mild hypernatremia and and that improved with hydration mental status also improved with correction of sodium and fluid balance please see below for medication changes acute issues worsening mental status anxiety depression the patient has a year history of bipolar disorder which is characterized by periods of hypomania irritability but a more chronic course of depression psychiatry evaluated patient and got collateral from psychiatrist dr psychiatry confirmed his medications as below acute on chronic agitation likely due to dehydration and hypernatremia as his symptoms resolved with resolution and hypernatremia as per dr sertraline and donepezil was discontinued home will be held in the setting of initiation of gabapentin to avoid over sedation dr will reinitiate as appropriate the patient was discharged on the following medications olanzapine mg daily olanzapine 5mg daily prn agitation trazodone mg qhs depakote mg daily bilateral lower extremity pain the patient has a history of diabetes and has a history of pain in bilateral legs workup inpatient has included foot xr neg for fx dopplers no evidence of dvt or cyst most likely etiology either diabetic neuropathy or osteoarthritis in coordination with outpatient psychiatrist dr was started on gabapentin 200mg tid with good effect hypernatremia cr previous cr in at was the creatinine improved with oral hydration the patient should continue to drink at least four oz glasses of water 64oz a day the hypernatremia resolved with oral hydration he should have his cmp checked by his pcp on follow up in chronic issues hypertension continueed home amlodipine and hydrochlorothiazide vascular dementia continued home asa history of dvt continue home warfarin mg daily diabetes continued home regimen insulin transitional issues please check inr next appointment and make adjustments as needed re evaluation for re initiation of as well as increasing olabnzapine 5mg as per dr changes new olanzapine 5mg daily olanzapine 5mg daily prn agitation gabapenitn 200mg tid dose changes depakote 500mg bid to daily discontinued medications sertraline 25mg daily held medications lamictal 100mg daily medications on admission the preadmission medication list is accurate and complete olanzapine mg po daily trazodone mg po qhs divalproex delayed release mg po bid warfarin mg po daily16 novolog mix u insuln insulin asp prt insulin aspart unit ml subcutaneous bid folic acid mg po daily amlodipine mg po daily hydrochlorothiazide mg po daily aspirin mg po daily thiamine mg po daily cyanocobalamin mcg po daily melatonin mg oral qhs atorvastatin mg po qpm lamotrigine mg po daily discharge medications gabapentin mg po tid olanzapine mg po daily prn agitation amlodipine mg po daily aspirin mg po daily atorvastatin mg po qpm cyanocobalamin mcg po daily divalproex delayed release mg po bid folic acid mg po daily hydrochlorothiazide mg po daily melatonin mg oral qhs novolog mix u insuln insulin asp prt insulin aspart unit ml subcutaneous bid olanzapine mg po daily thiamine mg po daily trazodone mg po qhs warfarin mg po daily16 held lamotrigine mg po daily this medication was held do not restart lamotrigine until directed by dr disposition home with service facility discharge diagnosis hypernatremia acute kidney injury 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 was a pleasure caring for you at why was i in the hospital because you were not feeling well what happened to me in the hospital we checked you labs and found that you were dehydrated we gave you fluids and your got better what should i do after i leave the hospital please drink at least four 16oz containers of water a day to prevent dehydration 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 penicillins attending chief complaint hip fracture major surgical or invasive procedure orthopedic surgery intramedullary nailing with a long tfn system x mm with mm lag screw history of present illness with dementia atrial fibrillation not on anticoagulation and history of traumatic subdural hematoma due to fall and resulting tbi presents from home after a mechanical fall the patient was unable to provide history due to very poor mental status in discussion with the patient s daughter in law the patient is reported to have poor mental status at baseline he has moments of lucidity but often he has difficulty carrying on conversation or following basic instructions he does ambulate at baseline he is totally dependent in iadls and now in most adls assistance with bathing dressing and toileting able to feed self if food provided of note he had been on hospice a year ago and was expected to survive days weeks however recovered surprisingly and has been living at home with wife also with advanced dementia and his son and daughter who are their primary caretakers he was in the living room with his wife when he had a fall it was only witnessed by his wife but his daughter in law says that it appeared he most likely was turning and tripped falling next to a table that he tried to grab as he landed close to it in the ed initial vitals were ra exam was notable for tender over right hip and femur only right leg mildly rotated no appreciable limb length shortening labs notable for hgb from baseline and cxr notable for moderate pulmonary edema hip xr showed r intertrochanteric fracture patient received iv furosemide mg iv morphine sulfate mg x2 orthopedics was consulted and recommended operative management he was admitted to medicine for optimization of volume status vitals prior to transfer were nasal cannula on arrival to the floor patient was not interactive or conversant past medical history atrial fibrillation not on warfarin hypertension hyperlipidemia bph benign prostatic hyperplasia gout history of traumatic subdural hemorrhage s p evacuation peripheral neuropathy osteoarthritis non convulsive status epilepticus history of clostridium difficile infection urinary tract infection edema congestive heart failure urinary incontinence bullous disorder social history family history unable to be obtained due to patient s mental status physical exam admission vitals on 2l gen elderly gentleman lying in bed asleep but rousable to sternal rub does not follow commands heent perrl pupils contracted 3mm to 2mm head appears atraumatic neck supple jvp difficult to appreciate but visibly distended external jugular vein up cm above clavicle cardiac rrr normal s1 and s2 no murmurs pul ctab no wheezes or crackles abd bs soft non tender non distended ext warm well perfused rle pitting edema to knee rle foreshortened and externally rotated skin multiple skin tears on arms and legs as well as old desquamated bullae neuro patient does not follow commands resists passive extension of all extremities discharge vs ra gen elderly chronically ill nad heent eomi mmm neck supple jvp difficult to appreciate but visibly distended external jugular vein up 5cm above clavicle cardiac rrr nmrg pul anterior crackles to midlung improved from yesterday breathing comfortably nc in place abd soft ntnd ext wwp rle pitting edema to knee skin multiple skin tears on arms and legs as well as old desquamated bullae neuro alert nonverbal does not follow commands resists passive extension of all extremities pertinent results labs admission 00pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00pm blood ptt 00pm blood glucose urean creat na k cl hco3 angap 00am blood calcium phos mg h h trend 00pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 21am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 28am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 57am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 35pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 02am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 28pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt discharge labs 15am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 15am blood glucose urean creat na k cl hco3 angap 15am blood calcium phos mg micro culture pendinginpatient cultureblood culture routine pendinginpatient cultureblood culture routine pendinginpatient culture final proteus mirabilis inpatient urine culture final proteus mirabilis organisms ml presumptive identification sensitivities mic expressed in mcg ml proteus mirabilis ampicillin s ampicillin sulbactam s cefepime s ceftazidime s ceftriaxone s ciprofloxacin s gentamicin s meropenem s piperacillin tazo s tobramycin s trimethoprim sulfa s imaging studies lower ext veins no evidence of deep venous thrombosis in the right lower extremity veins right calf subcutaneous edema portable ap previous moderate pulmonary edema has improved moderate bilateral pleural effusions have redistributed dependently but probably not enlarged and nowobscure the right heart border opacification at the lung bases is probably a combination of atelectasis dependent edema overlying pleural effusion no pneumothorax unilat min views images from the operating suite show placement of a fixation device about fracture of the proximal femur further information can be gathered from the operative report extremity fluoro images from the operating suite show placement of a fixation device about fracture of the proximal femur further information can be gathered from the operative report atrial fibrillation with a moderate ventricular response occasional ventriclar premature beats with one couplet left axis deviation consistent with left anterior fascicular block non specific repolarization abnormalities possible old anteroseptal myocardial infarction compared to the previous tracing of no change except for ventricular ectopy now present portable ap in comparison with the study of there again is enlargement of the cardiac silhouette with asymmetric pulmonary edema as previously it would be difficult to unequivocally exclude superimposed pneumonia especially in the absence of a lateral view hazy opacifications bilaterally with poor definition of the hemi diaphragms suggests layering pleural effusion with underlying compressive atelectasis no interval change no evidence of pneumothorax atrial fibrillation with a moderate ventricular response left anterior fascicular block possible old anteroseptal myocardial infarction non specific repolarization abnormalities compared to the previous tracing of the rate is slower without other significant change ap lat right no acute fracture seen of the mid to distal right femur single view prominent right greater than left perihilar is opacities worrisome for severe pulmonary edema asymmetric increased opacity on the right as compared to the left could be due to asymmetric pulmonary edema versus underlying infection and or aspiration pulmonary hemorrhage not excluded subtle posterolateral right sided rib deformities including right fourth through seventh ribs consistent with rib fractures the right fourth and seventh rib fractures appear old the right fifth and sixth rib fractures are of indeterminate age but could be acute to subacute correlate with clinical history and site of point tenderness findings are new since unilat view w p comminuted right intertrochanteric fracture with varus angulation of the right femoral head moderate to severe right hip osteoarthritic changes c spine w o contrast no acute fracture of the cervical spine multi level degenerative changes partially imaged right greater than left pleural effusions pulmonary edema head w o contrast some patient motion limits the exam no definite acute intracranial process seen baseline artifact limits the sensitivity of interpretation the rhythm is probably atrial fibrillation with rapid ventricular response occasional ventricular premature contraction and aberrantly conducted complexes left axis deviation possible inferior wall myocardial infarction of indeterminate age poor r wave progression in leads v1 v3 possible anteroseptal myocardial infarction of indeterminate age delayed r wave transition diffuse non specific st segment changes with biphasic t waves in lead v6 cannot exclude possible myocardial ischemia clinical correlation is suggested compared to the previous tracing of the ventricular rate has increased by about beats per minute and the lateral st t wave changes are slightly more pronounced brief hospital course with dementia atrial fibrillation not on anticoagulation and history of traumatic subdural hematoma due to fall and resulting tbi presents from home after a mechanical fall found to have a right intertrochanteric fracture this was repaired by orthopedic surgery s p r intertrochanteric fracture hip was repaired complicated by mild bleeding into r thigh r more swollen than l dopplers negative for dvt his enoxaparin was stopped and restarted anemia pt developed acute blood loss anemia from bleeding into r thigh he received 2u prbcs and was monitored for development of compartment syndrome his h h stabilized by day of discharge hbg dchf patient had an episode of hypoxemia in the pacu that resolved with diuresis most likely a mild exacerbation of his diastolic chf he was restarted on home diuretics but then these were stopped as the patient was no longer volume overloaded and developed hypernatremia likely secondary to poor po intake the patient was discharged off home lasix will need daily weights to determine whether these should be restarted hypernatremia patient developed mild hypernatremia na on day of discharge likely secondary to poor po intake received mivf of d5w consider need to continue d5w for hypernatremia uti pt developed uti tx ed w cipro bid x7d which he completed on htn patient s home carvedilol was continued lisinopril held but restarted on day of discharge given sbps 120s 150s dementia of note he is totally dependent in iadls and now in most adls assistance with bathing dressing and toileting able to feed self if food provided of note he had been on hospice a year ago and was expected to survive days weeks however recovered surprisingly and has been living at home with wife also with advanced dementia and his son and daughter who are their primary caretakers malnutrition nutrition provided recommendations pt discharged on multivitamin likely contributing to inr of transitional issues please check cbc on discharge hgb was transfuse for hbg patient was started on enoxaparin for prophylaxis consider continued need for this at outpatient follow up appointment f u with orthopedics scheduled for patient s home diuretics lasix mg po bid were held in the setting of hypernatremia please weigh the patient daily to assess need to restart diuretics weight on kgs the patient s sodium on day of discharge was likely secondary to poor po intake and he was given d5w please check sodium regularly every other day or so and give d5w at a slow rate prn for hypernatremia patient with minor coagulopathy inr on day of discharge likely secondary to malnutrition consider nutritional supplements pt started on multivitamin patient s home bp lisinopril was restarted on day of discharge sbps were 120s 150s and he had normal renal function and normal k medications on admission the preadmission medication list may be inaccurate and requires futher investigation potassium chloride meq po daily lisinopril mg po daily carvedilol mg po bid furosemide mg po bid terbinafine cream appl tp daily discharge medications carvedilol mg po bid bisacodyl mg po pr daily prn constipation clobetasol propionate cream appl tp bid lactulose ml po bid prn constipation milk of magnesia ml po bid prn dyspepsia acetaminophen mg po tid pain docusate sodium mg po bid enoxaparin sodium mg sc q12h start today first dose next routine administration time multivitamins w minerals tab po daily lisinopril mg po daily discharge disposition extended care facility discharge diagnosis primary r hip fracture acute blood loss anemia diastolic chf acute on chronic uti complicated secondary coagulopathy malnutrition advanced dementia hypertension discharge condition mental status confused always level of consciousness lethargic but arousable activity status out of bed with assistance to chair or wheelchair discharge instructions dear mr you were seen at for hip fracture this was repaired by orthopedic surgery and we gave you blood to treat some expected postsurgical thigh bleeding please see your appointments and medications below you have a follow up appointment with orthopedic surgery sincerely your medicine team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies sulfa sulfonamide antibiotics lisinopril hydrocodone doxycycline clindamycin cephalexin bee sting e mycin vicodin keflex attending chief complaint abnormal labs major surgical or invasive procedure none history of present illness with t2dm htn chf cad s p cabg obesity and esrd referred by his nephrologist for with decreased uop he was sent in to the ed for elevated cr of from baseline he was evaluated by his pcp and was found to have cr he has been off losartan and furosemide for hours patient reports poor appetite and increased fatigue over the past few days denies fevers vomiting diarrhea he has been keeping up with his fluids and making an effort to drink plenty but his uop is about of normal in the ed initial vital signs were ra exam notable for rue avf labs were notable for cr from baseline co2 ag h h u a with prot otherwise bland flu a b pcr negative renal was consulted and recommended gentle ivf hold and admit to medicine patient was given 2l ns vitals on transfer ra upon arrival to the floor the patient feels well he reports some mild doe but denies fever chills recent illness sore throat chest pain peripheral edema orthopnea sob at rest abd pain n v d black or bloody stools dysuria hematuria weak stream post void fullness focal weakness or falls review of systems positive as per hpi past medical history t2dm c b diabetic neuropathy nephropathy neuropathy cad s p cabg hld osa on cpap bph history of asbestosis and history of agent orange exposure patient has a month exposure history to agent orange during his time in the in and in extensive workup was performed since his initial visit with us in light of his asbestosis and agent orange exposure he has met with heme onc id gi and urology and was cleared by them for transplant social history family history dm cad mi cva breast cancer physical exam admission physical exam vitals ra general wnwd male in nad laying in bed heent anicteric perrl eomi mom op clear neck supple no lad no elevated jvd cardiac rrr soft hs normal s1s2 no m r g lungs mildly dyspneic with exertion of exam maneuvers ctab back no cvat abdomen obese soft nt nd nabs extremities wwp chronic venous stasis changes ble without current edema rue avf with good thrill and bruit skin warm dry neurologic a ox3 cn ii xii intact ble numbness strength no asterixis gait not assessed discharge physical exam vital signs t po bp hr rr o2 sat general no acute distress sitting up on side of bed heent mucous membranes moist cardiac rrr soft hs normal s1s2 lungs ctab no wheezing abdomen obese soft nt nd extremities wwp chronic venous stasis changes ble without current edema rue avf with good thrill and bruit skin warm dry neurologic a ox3 moves all extremities spontaneously pertinent results admission labs 00pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 20am blood 00pm blood glucose urean creat na k cl hco3 angap 20am blood calcium phos mg 02pm urine color yellow appear clear sp 02pm urine blood neg nitrite neg protein glucose neg ketone neg bilirub neg urobiln neg ph leuks neg 02pm urine rbc wbc bacteri none yeast none epi 02pm urine hours random urean creat na 02pm urine mucous rare microbiology pm urine final report urine culture final cfu ml discharge labs 11am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 11am blood glucose urean creat na k cl hco3 angap 11am blood calcium phos mg brief hospital course mr is a male with history of t2dm htn chf cad s p cabg in obesity and ckd not on dialysis admitted for on ckd likely in the setting of poor po intake acute on chronic kidney injury the patient presents with worsening cr in the setting of dm nephropathy baseline cr is patient had been advised to hold his home losartan and lasix hours prior to presentation which continued to be held during his hospital stay he currently has a fistula in the right upper extremity that is functional but has not yet started dialysis feurea and improvement in cr with ivf are consistent with pre renal azotemia patient denied any focal infectious symptoms and remained hemodynamically stable most likely etiology is significantly decreased po intake in the setting of worsening uremia nutrition evaluated the patient and his meals were complemented with nepro supplements creatinine on discharge is he will continue calcium carbonate nephrocaps ascorbic acid vitamin d losartan and lasix will be held until labs are drawn at his pcp s office and decision to restart will be based off those results fever spiked a fever to on which resolved without tylenol given that he did not endorse any infectious focal symptoms additional workup was deferred he was monitored for hours thereafter and remained afebrile hypertension elevated sbps to 150s 170s 70s 80s likely in the setting of holding home losartan and lasix due to patient s per nephrology these medications will continue to be held until patient has repeat labs drawn at his pcp s office to ensure resolution of dysphagia patient reported dysphagia and odynophagia on the day prior to discharge he was evaluated by speech and swallow who did not think he was at risk for aspiration continue to monitor at future visits cad s p cabg no evidence of cardiac decompensation of heart failure continue aspirin metoprolol and atorvastatin diabetic retinopathy continue valproic acid reportedly prescribed by his retina specialist patient denies seizure history gerd continue omeprazole diabetes mellitus followed by on home lantus units qhs decreased to units qhs in the setting of his allergies continue loratidine prn osa continue cpap at night gout stable continue allopurinol mg po daily transitional issues acute kidney injury on ckd advise repeat bmp at pcp s visit before restarting losartan and furosemide encourage nutritional supplementation and increased po intake as he is at risk for given progression of his ckd concern for progression of ckd not candidate for hemodialysis initiation at this time but may need to consider it in the future has functional rue fistula in place cr on discharge k on discharge hypertension consider restarting losartan and furosemide after repeat bmp blood pressure on discharge dysphagia consider ent follow up if patient reports continued dysphagia evaluated by speech swallow who did not think he was at risk for aspiration contact name of health care proxy relationship wife phone number cell phone code full confirmed medications on admission the preadmission medication list is accurate and complete calcium carbonate mg po daily valproic acid mg po q12h allopurinol mg po daily metoprolol succinate xl mg po daily docusate sodium mg po daily atorvastatin mg po qpm insulin aspart unit ml sc sliding scale insulin glargine unit ml ml subcutaneous qhs furosemide mg po qam furosemide mg po 2pm daily corvite free mv min cmb mg mcg mcg mg oral daily sildenafil mg oral daily prn omeprazole mg po daily aspirin mg po daily loratadine mg po daily prn runny nose b complex with c folic acid mg oral daily ascorbic acid mg po daily vitamin d unit po 1x week we discharge medications nephrocaps cap po daily rx b complex with c folic acid renal caps mg capsule s by mouth daily disp capsule refills allopurinol mg po daily ascorbic acid mg po daily aspirin mg po daily atorvastatin mg po qpm b complex with c folic acid mg oral daily calcium carbonate mg po daily corvite free mv min cmb mg mcg mcg mg oral daily docusate sodium mg po daily insulin aspart unit ml sc sliding scale insulin glargine unit ml ml subcutaneous qhs loratadine mg po daily prn runny nose metoprolol succinate xl mg po daily omeprazole mg po daily sildenafil mg oral daily prn valproic acid mg po q12h vitamin d unit po 1x week we held furosemide mg po qam this medication was held do not restart furosemide until you see your pcp or nephrologist held furosemide mg po 2pm daily this medication was held do not restart furosemide until you see your pcp or nephrologist held furosemide mg po 2pm daily this medication was held do not restart furosemide until you see your pcp or nephrologist outpatient lab work please draw on na k cl hco3 bun cr glucose ca mg icd chronic kidney disease fax results to attn dr disposition home discharge diagnosis primary diagnoses acute on chronic kidney disease due to reduced fluid intake hypertension secondary diagnoses cad diabetes mellitus osa gerd discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr you were hospitalized at in the setting of an acute injury on your long standing kidney disease this can occur when you are not eating or drinking enough we think your decreased appetite contributed to this insult as your kidney function improved with fluids we do not think an infection caused this acute injury you also reported difficulty swallowing food for the past few days our speech and swallow team evaluated you and do not think that you are at risk for choking if you have worsening symptoms it is important to make your pcp aware of these issues your lasix and losartan have been held given this acute kidney injury they should continue to be held until you see your pcp or nephrologist who feel that it is safe to restart these medications you will have labs drawn when you see your pcp to evaluate your kidney function it is extremely important to keep your appetite up you should supplement your meals with nepro shakes they can be purchased at the pharmacy it is important to attend your follow up appointments listed below it was a pleasure taking care of you we wish you the best your team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies sulfa sulfonamide antibiotics lisinopril hydrocodone doxycycline clindamycin cephalexin bee sting e mycin vicodin keflex attending chief complaint hd initiation major surgical or invasive procedure none history of present illness mr is a w history of ckd stage t2dm c b diabetic nephropathy and retinopathy hypertension cad s p cabg and obesity who presents to for scheduled admission for initiation of hd he has had worsening renal function over the past several years and had avf placed in he had remained stable until over the past couple of months over that time he has noticed becoming more fatigued he often will lounge around during the day and often has difficulty with attention per his wife he has also had worsening shortness of breath over the past couple of weeks especially with ambulation he has had chronic lower extremity edema that has worsened over this time period he continues to make urine and has responded to po furosemide as an outpatient he denied any nausea vomiting metallic taste or asterixis he underwent first session of hd today for which he tolerated he underwent hd for hours with 0cc uf upon arrival to the floor he has no complaints he otherwise feels well and is ready to get through the rest of his hd sessions in order to be discharged ros positive per hpi remaining point ros reviewed and negative past medical history t2dm c b diabetic neuropathy nephropathy last hemoglobin a1c was on ckd stage v cad s p cabg cva hld osa on cpap bph gerd seasonal allergies history of asbestosis and history of agent orange exposure right av fistula placement social history family history dm cad mi cva breast cancer physical exam admission physical exam vital signs t bp hr rr spo2 on ra general well developed male in nad aox3 heent nc at mmm op clear neck supple difficult jvp exam due to body habitus cardiac rrr normal s1 and s2 no mgr lungs non labored respirations clear to auscultation bilaterally no wheezing or rhonchi abdomen soft obese non tender to palpation normoactive bowel sounds extremities compression stockings on bilateral lower extremities with pitting edema neurologic no asterixis no focal neurologic deficits skin no discernible rashes access rue avf bruit thrill discharge physical exam vital signs ra general well developed male in nad aox3 heent nc at mmm op clear neck supple difficult jvp exam due to body habitus cardiac rrr normal s1 and s2 no mgr lungs non labored respirations clear to auscultation bilaterally no wheezing or rhonchi abdomen soft obese non tender to palpation normoactive bowel sounds extremities bilateral lower extremities with pitting edema neurologic no asterixis no focal neurologic deficits skin no discernible rashes access rue avf bandaged pertinent results admission labs 12pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 12pm blood glucose urean creat na k cl hco3 angap 12pm blood calcium phos mg 12pm blood hbsag neg hbsab neg hbcab neg 12pm blood hcv ab neg 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 imaging results cxr impression no acute cardiopulmonary abnormality brief hospital course mr is a w history of ckd stage t2dm c b diabetic nephropathy and retinopathy hypertension cad s p cabg and obesity who presents to for scheduled admission for initiation of hd acute issues ckd stage v hd initiation patient with ckd in setting of diabetic nephropathy who had planned admission for hd initiation his indication for hd is uremia with worsening fatigue and mentation at home he successfully under four sessions of hd during his hospitalization without issue he remained on home calcitriol and nephrocaps he will continue po furosemide 40mg on non hd days plan to start hd as outpatient on with plan to keep mwf schedule hypertension patient has history of hypertension on furosemide and metoprolol as outpatient his bp was persistently elevated while hospitalized he was started on amlodipine 5mg with mild improvement in bp chronic issues iddm patient managed by as outpatient he remained on home lantus 18u qpm and home humalog iss anemia hgb low in setting of ckd stable diabetic retinopathy continue valproic acid bid cad continue asa and statin gout continue allopurinol at hd dosing seasonal allergies continue home loratadine and flonase gerd continue home omeprazole transitional issues starting hd at dialysis center on schedule continue taking furosemide 40mg on non dialysis days consider uptitration of amlodipine or additional anti hypertensive agents for bp management notably has a h o edema with nifedipine but this was not seen with amlodipine home loratadine and allopurinol were dose adjusted for hd needs hepatitis b immunization given non hep b immune status code full presumed contact wife medications on admission the preadmission medication list is accurate and complete allopurinol mg po daily atorvastatin mg po qpm aspirin mg po daily metoprolol succinate xl mg po daily vitamin d unit po 1x week omeprazole mg po daily valproic acid mg po q12h loratadine mg po daily furosemide mg po daily ascorbic acid mg po daily caps b complex with c folic acid mg oral daily calcitriol mcg po 3x week viagra sildenafil mg oral daily prn docusate sodium mg po tid calcium carbonate mg po daily glargine units bedtime insulin sc sliding scale using hum insulin fluticasone propionate nasal spry nu daily ipratropium bromide nasal daily prn glucosamine glucosamine sulfate mg oral daily discharge medications amlodipine mg po daily rx amlodipine mg tablet s by mouth daily disp tablet refills allopurinol mg po every other day furosemide mg po 4x week glargine units bedtime insulin sc sliding scale using hum insulin loratadine mg po every other day ascorbic acid mg po daily aspirin mg po daily atorvastatin mg po qpm calcitriol mcg po 3x week calcium carbonate mg po daily docusate sodium mg po tid fluticasone propionate nasal spry nu daily glucosamine glucosamine sulfate mg oral daily ipratropium bromide nasal daily prn metoprolol succinate xl mg po daily omeprazole mg po daily caps b complex with c folic acid mg oral daily valproic acid mg po q12h viagra sildenafil mg oral daily prn vitamin d unit po 1x week discharge disposition home discharge diagnosis primary diagnoses chronic kidney disease hemodialysis initiation hypertension secondary diagnoses iddm cad osa gout seasonal allergies gerd 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 why were you admitted you were admitted to start dialysis what happened during your hospitalization you started dialysis without any problems you were started on a new blood pressure medication what should you do once you leave the hospital please take all of your medications as prescribed some of the dosages of your home medications have changed since you are now on dialysis please follow up with all of your physicians as noted below again it was a pleasure taking care of you all the best your team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies no known allergies adverse drug reactions attending major surgical or invasive procedure none attach 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 glucose urean creat na k cl hco3 angap notable labs 40am blood caltibc vitb12 folate hapto ferritn trf 40am blood homocys 40am blood tsh 40am blood methylmalonic acid pending micro mrsa screen nasal swab pending urine strep pneumo antigen pending urine legionella antigen negative for serogroup flu a b pcr negative respiratroy viral panel pending ucx mixed bacterial flora final imaging cxr impression findings concerning for multifocal pneumonia in the right lung ct chest w contrast impression diffuse ground glass opacification throughout bilateral lungs in a peribronchovascular distribution differential considerations include atypical viral infection sarcoidosis hypersensitivity pneumonitis drug toxicity or respiratory bronchiolitis interstitial lung disease given the history smoking bilateral pulmonary nodules measuring up to mm are stable dating back to mild confluent bilateral hilar lymphadenopathy discharge labs 30am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30am blood glucose urean creat na k cl hco3 angap 30am blood albumin calcium phos mg brief hospital course smoker with history of cardiomyopathy hypertension asthma copd prior desquamative interstitial pneumonia who presents with several weeks of cough and shortness of breath found to have hypoxia acute hypoxic respiratory failure copd exacerbation vaping related lung disease hypoxia improved from 4l ra w prednisone standing duonebs empiric abx ct chest showing ggos throughout b l upper middle lobes consistent with ild and no evidence of consolidation to suggest pna pulmonology was consulted they felt that her presentation was most likely due to recent vaping stopped zosyn given no convincing evidence for bacterial pneumonia no new fevers or worsening respiratory symptoms off abx ambulatory vs on day of discharge were rr and pox on room air discharged on duoneb taper prednisone taper decrease by mg every days per pulm recs with plans to follow up with dr primary fyi we submitted confidential report to ma dph re vaping related lung disease needs cxr in weeks to document improvement nicotine dependence active smoking tobacco cigarettes marijuana use vaping thc using dab pen provided extensive counseling and motivational interviewing regarding cessation of both smoking and vaping patient demonstrated fair insight and seemed motivated to abstain from both smoking and vaping we initiated both nicotine patch and gum while in the hospital mg patch was not enough so went up to the mg patch she has dentures so preferred the lozenge to the gum on discharge we prescribed both patch and lozenge and encouraged her to discuss potential medical treatment options to help her abstain from smoking with her pcp e g buproprion or chantix needs ongoing support w smoking cessation possibly medication assistance anxiety moderate anxiety while inpatient likely due to combination of cigarette smoking cessation marijuana cessation and significant social stressors treated w prn hydroxyzine to good effect anemia b12 deficiency folate deficiency was noted to have significant anemia hgb nadir of that was relatively normocytic mcv routine anemia labs revealed low vit b12 and undetectable folate she reported that she had received b12 shots earlier this year mma and homocysteine were ordered homocysteine was slightly elevated mma still pending at the time of discharge tsh was wnl at ferritin and tsat were not low to suggest concomitant iron deficiency treated with one dose of im vit b12 one dose of iv folic acid and initiated on po folic acid on discharge please recheck b12 folate levels as appropriate and evaluate for underlying causes of these significant deficiencies if persistently low hx of cardiomyopathy lvef thought to be post partum held home metoprolol lisinopril during hospitaliazation given sbps frequently between please resume home cardiac meds at upcoming primary care appointment as long as bp not low time in care minutes in discharge related activities on the day of discharge medications on admission the preadmission medication list is accurate and complete levothyroxine sodium mcg po daily lisinopril mg po daily metoprolol succinate xl mg po daily vitamin d unit po daily albuterol inhaler puff ih q4h prn sob symbicort budesonide formoterol mcg actuation inhalation bid discharge medications famotidine mg po q12h duration days take until prednisone taper is complete rx famotidine mg tablet s by mouth twice a day disp tablet refills folic acid mg po daily rx folic acid mg tablet s by mouth once a day disp tablet refills guaifenesin dextromethorphan ml po q6h prn cough rx dextromethorphan guaifenesin mg mg ml ml by mouth q6h prn refills ipratropium albuterol neb neb neb asdir duration days taper by neb every days qid qid tid tid bid bid daily daily stop rx ipratropium albuterol mg mg mg base ml neb inh asdir disp ampule refills nicotine lozenge mg po q1h prn cigarette craving rx nicotine polacrilex mg one mg lozenge q1h prn disp lozenge refills nicotine patch mg day td daily rx nicotine mg hour mg hour mg hour apply patch transdermally once a day disp box refills prednisone mg po daily duration doses start today first dose next routine administration time taper as directed this is dose of tapered doses rx prednisone mg asdir tab by mouth once a day disp tablet refills prednisone mg po daily duration doses start after mg daily tapered dose taper as directed this is dose of tapered doses prednisone mg po daily duration doses start after mg daily tapered dose taper as directed this is dose of tapered doses prednisone mg po daily duration doses start after mg daily tapered dose taper as directed this is dose of tapered doses albuterol inhaler puff ih q4h prn sob levothyroxine sodium mcg po daily symbicort budesonide formoterol mcg actuation inhalation bid puffs bid rx budesonide formoterol symbicort mcg mcg actuation puff inh twice a day disp inhaler refills vitamin d unit po daily held lisinopril mg po daily this medication was held do not restart lisinopril until instructed to do so by your pcp held metoprolol succinate xl mg po daily this medication was held do not restart metoprolol succinate xl until instructed to do so by your pcp outpatient physical therapy outpatient pulmonary rehabilitation please evaluate and treat as needed for recent copd exacerbation with acute hypoxic respiratory failure and vaping induced lung injury icd discharge disposition home discharge diagnosis vaping induced lung disease copd exacerbation w acute hypoxic respiratory failure active smoking nicotine dependence anemia b12 deficiency folate deficiency discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent vs t po bp hr rr pox ra ambulatory vs rr and pox on room air gen nad heent anicteric sclera mmm chest mild inspiratory crackles over b l mid lung zones no wheezing or rhonchi expiratory phase not significant prolonged forceful coughing at times cv rr no m r g distal pulses no peripheral edema abd s nt nd bs neuro awake alert conversant w clear speech stable gait discharge instructions dear you were admitted to the hospital with severe shortness of breath and hypoxia low oxygen we believe this was caused by a combination of your chronic lung disease copd from smoking and recent vaping imaging studies showed inflammation of your lungs but fortunately this improved with nebulizer treatments and steroids prednisone you were evaluated by the lung specialists who recommended a gradual taper of the prednisone and have contacted your primary lung doctor to help arrange a follow up appointment as we discussed the most important thing you can do to prevent this from happening again is to not smoke cigarettes or anything else and do not vape if you are going to use marijuana products please consume edibles in safe amounts in order to help you quit smoking and stay off cigarettes you are being discharged on a nicotine patch as well as nicotine lozenges use the nicotine patch as instructed on the box if you have a craving for a cigarette despite the nicotine patch use the nicotine lozenges plan to talk with dr at your upcoming appointment about how your efforts at quitting smoking are going and if any additional medications might be helpful you were found to have anemia with low vitamin b12 and low folic acid levels you were given a b12 shot and a dose of iv folic acid prior to discharge you should also take folic acid at home each day dr will follow up on your anemia and your low vitamin levels in clinic lastly your home blood pressure medications lisinopril and metoprolol were not given during this hospitalization because your blood pressure was normal without them we are holding these medications on discharge and you can discuss with dr if you need to resume one or both of these medications in the future it was a pleasure caring for you and we wish you a full and speedy recovery sincerely your medicine team followup instructions

name unit no admission date discharge date date of birth sex m service neurosurgery allergies no allergies adrs on file attending chief complaint fall major surgical or invasive procedure none history of present illness year old male with a history of afib on xarelto who presents with a fall with a left sdh repeat scan showing right frontal contusion left temporal contusion and bilateral sah past medical history atrial fibrillation hcc chf congestive heart failure diabetes mellitus high cholesterol hypertension prediabetes dyslipidemia typical atrial flutter hcc abdominal aortic aneurysm without rupture hcc pharyngoesophageal dysphagia disturbance of salivary secretion hypovitaminosis d pleural plaque cognitive impairment tobacco use disorder laryngopharyngeal reflux lpr at risk for falls non rheumatic mitral regurgitation social history family history nc physical exam on admission gcs in ed heent abrasion to left lateral head otherwise atraumatic neck in a c collar otherwise supple extrem warm and well perfused neuro mental status somnolent but opens eyes quickly to voice awake alert cooperative throughout exam normal affect extremely hard of hearing orientation oriented to self tangential speech as answers to other questions language speech is fluent with receptive aphasia cranial nerves i not tested ii pupils equally round and reactive to light to 2mm bilaterally iii iv vi extraocular movements grossly intact bilaterally without nystagmus v vii facial strength and sensation intact and symmetric viii hearing intact to voice ix x palatal elevation symmetrical xi sternocleidomastoid and trapezius normal bilaterally xii tongue midline without fasciculations motor normal bulk and tone bilaterally no abnormal movements tremors moves all extremities against resistance but does not follow complex motor exam sensation withdraws to light touch in all extremities at discharge expired pertinent results please see the omr for pertinent results brief hospital course subarachnoid hemorrhage bilateral iph following emergency department evaluation and imaging demonstrating multiple areas of bleeding without midline shift the patient was admitted to the neuro icu he was started on keppra and made npo with regular neuro checks he had a repeat ct scan the following morning to assess interval changes which demonstrated an increased size of hemorrhagic contusions with increased surrounding edema as well as mild mass effect with rightward movement of the left uncus but without clear uncal herniation the patient was followed closely with repeat head ct s which showed expansion of the intracranial bleeds on a family meeting was held and it was determined that he patient would be extubated the following day if his exam does not improve on he was extubated he expired on medications on admission medications at home cephalexin keflex mg capsule take capsule by mouth four times daily atorvastatin lipitor mg tablet take tablet by mouth daily fluticasone flonase mcg act nasal spray sprays by each nostril route daily rivaroxaban xarelto mg tabs take tablet by mouth daily with dinner furosemide lasix mg tablet take tablet by mouth once daily metformin glucophage mg tablet take tablet by mouth twice a day with meals ergocalciferol vitamin d2 unit capsule take capsule by mouth once a week erythromycin romycin ophthalmic ointment losartan cozaar mg tablet take tablet by mouth once daily digoxin digitek mg tablet take tablet by mouth daily carvedilol coreg mg tablet take tablet by mouth two times daily with meals latanoprost xalatan ophthalmic solution potassium chloride klor con meq packet take meq by mouth two times daily discharge medications none expired discharge disposition expired discharge diagnosis right frontal iph left temporal iph discharge condition expired discharge instructions expired followup instructions

name no admission date discharge date date of birth sex f service medicine allergies no known allergies adverse drug reactions attending chief complaint dyspnea on exertion difficulty managing anticoagulation major surgical or invasive procedure implant left atrial appendage device history of present illness old female with h o htn paroxysmal atrial fibrillation multiple embolic cva microscopic polyangiitism anca vasculitis treated with steroids ckd mycobacterial lung infection and sah s p craniotomy and clip ligation in referred for implant as she has a history of medication non compliance previously not compliant with eliquis currently on coumadin past medical history ckd chronic kidney disease stage iv subarachnoid hemorrhage s p craniotomy l ica bifurcation aneurysm microscopic polyangiitis cerebrovascular accident due to embolism paroxysmal atrial fibrillation cerebrovascular accident due to embolism of vertebral artery unspecified blood vessel laterality anticoagulant long term use social history family history patient does not believe there is a family history of aneurysms mother with unknown cancer physical exam admission pe vs bp hr rr spo2 2lnc gen patient is in no acute distress heent face symmetrical eyes perrl bilaterally trachea midline neuro a ox3 able to answer questions and follow commands no focal deficits no tongue deviation able to give thumbs up bilaterally and wiggle toes bilaterally pulm breathing unlabored breath sounds clear bilaterally cardiac no jvd no thrills or bruits heard on carotids bilaterally s1 s2 rrr no splitting of heart sounds murmurs s3 s4 or friction rubs heard vasc no edema noted in bilateral upper or lower extremities no pigmentation changes noted in bilateral upper or lower extremities skin dry warm bilateral radial pulses palpable access right femoral access site soft tender with palpation no swelling drainage or hematoma noted no bruits ausculated abd rounded soft non tender discharge pe vs t 2f hr rr o2 sat on ra bp weight kg lbs telemetry sr hr no events gen sitting up in bed nad neuro a o to self place setting month year pleasant and conversant no further garbled speech clear rue all other extremities no sensory deficits noted facial symmetry heent normocephalic anicteric oropharynx moist neck supple trachea midline no jvd cv rrr s1s2 pulm ls cta bilaterally non labored breathing abd soft nontender bs x4 extr no edema bilaterally dp skin warm dry intact no open lesions access sites r groin suture removed tender to palpation mild ecchymosis small hematoma gu voiding independently pertinent results ep report successful implant of 21mm watchman device in the via the right femoral vein without complications hours of bedrest overnight observation aspirin 81mg daily c w warfarin tee in days f u with dr month head ct no intracranial hemorrhage multifocal small hypodensities within the bilateral basal ganglia corona radiata and periventricular white matter may correspond to chronic lacunar infarcts and microangiopathy mri could be obtained to better assess for acute infarct mri findings artifact in the left frontal region from aneurysm clip limits evaluation in this area there are scattered elongated foci of slow diffusion in the left greater than right centrum semiovale and corona radiata compatible with small acute infarctions there are multiple small chronic infarctions in the left greater than right centrum semiovale and bilateral basal ganglia additional punctate infarctions are noted in the pons gradient recalled echo images demonstrate multiple punctate foci of hypointense signal predominantly in a peripheral distribution findings are most consistent with cerebral amyloid angiopathy again seen and unchanged is superficial siderosis in the left sylvian fissure patchy to confluent areas of t2 and flair hyperintense signal abnormalities in the periventricular and subcortical white matter are nonspecific but likely reflect chronic small vessel ischemic changes mild prominence of the ventricles and sulci is suggestive of involutional changes there is no mass effect or midline shift there are dilated perivascular spaces there is mild mucosal thickening of the paranasal sinuses mild fluid signal is seen in the bilateral mastoid air cells the intraorbital contents are unremarkable impression small acute infarctions in the left greater than right centrum semiovale and corona radiata the findings are typical for hypoperfusion and watershed infarctions multiple small chronic infarctions in the bilateral centrum semiovale and basal ganglia as well as the pons findings of cerebral amyloid angiopathy mild parenchymal volume loss probable extensive chronic small vessel ischemic disease tte conclusion there is normal left ventricular wall thickness with a normal cavity size there is normal regional left ventricular systolic function quantitative biplane left ventricular ejection fraction is normal normal right ventricular cavity size with normal free wall motion the aortic valve leaflets are mildly thickened there is no aortic valve stenosis there is a trivial pericardial effusion neither the left atrial appendage nor the occluder device were well visualized compared with the prior tte recommend if clinically indicated a tee is suggested for further evaluation of watchman device brief hospital course ms is a year old female with h o htn ckd microscopic polyangiitism anca vasculitis treated with steroids paroxysmal atrial fibrillation multiple embolic strokes s p craniotomy and clip ligation referred for watchman implant as she has h o medication non compliance with eliquis she has been on coumadin with therapeutic inrs since she underwent successful implant post procedure course was complicated by rue weakness in the pacu with word finding difficulty code stroke called ct imaging unremarkable mri overnight was significant for small embolic infarcts bilaterally left greater than right typical for watershed event atrial fibrillation with history of sah s p watchman implant device complicated by small embolic stroke asa mg daily continue warfarin 5mg daily for days with weekly inrs for the next days unable to switch to apixiban at this time due to deductible of month for first month sbe prophylaxis x mos post procedure follow up tee in days follow up with np embolic cva rue weakness with pronator drift and garbled speech code stroke called with ct and mri results as above seen by acute while in patient with recommendation for acute rehab appreciate neurology recommendations keep hob at deg for aspiration precautions and to maximize cerebral perfusion allow bp to autoregulate no need for stroke work up labs given that she was worked up recently and risk factors known follow up with neurology as previously scheduled continue current anticoagulation regimen patient has now been seen by ot s s appreciate recommendations acute rehab appreciate speech and swallow recommendations diet nectar thick liquids regular solids medications whole in puree aspiration precautions strict assist ensure small bites sips ensure slow rate cup sips only no straws reduce distractions no talking lights on tv off phone put away tid oral care if continued dysphonia pt may benefit from further workup by ent and may also benefit from voice therapy upon d c as an outpatient within home gi nutrition diet as above cardiac heart healthy diet once passes bowel regimen with senna miralax renal baseline cr today continue to trend psychiatric behavioral mood stable no active issues dispo to acute rehab on transitional continue warfarin for next days with weekly inrs tee in days as schedule follow up with np as scheduled medications on admission the preadmission medication list is accurate and complete acetaminophen mg po q4h prn pain mild fever carvedilol mg po bid warfarin mg po daily16 nifedipine extended release mg po daily atorvastatin mg po qpm discharge medications aspirin mg po daily acetaminophen mg po q4h prn pain mild fever atorvastatin mg po qpm carvedilol mg po bid nifedipine extended release mg po daily warfarin mg po daily16 discharge disposition extended care facility discharge diagnosis subarachnoid hemorrhage s p craniotomy and clip ligation paroxysmal atrial fibrillation on warfarin with high risk for bleeding now s p watchman device periprocedural embolic cva discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear ms it was a pleasure taking care of you at the why was i in the hospital what happended in the hospital you had a watchman device implanted to decrease the risk of stroke due to atrial fibrillation you developed right arm weakness after the procedure and an mri of your head confirmed you had new areas of small strokes the weakness in your right arm and your difficulty with speech is much improved the neurology team the physical and occupational therapists agree that you will need acute rehab for continued work with speech and ot what should i do when i go home take all of your medications as prescribed listed below continue taking your warfarin for at least the next days and then otherwise directed by dr you are currently taking 5mg once daily your inr today when you are discharged from rehab anticoagulation will continue to follow your inrs you should also continue to take aspirin 81mg daily activity restrictions and information related to care of the access sites in the groin are included in your discharge instructions you will need prophylactic antibiotics prior to any dental procedure for the next months please inform your dentist about your recent cardiac procedure and obtain a prescription from your doctor before any procedure including dental cleanings follow up with your doctors as listed below it was a pleasure participating in your care if you have any urgent questions that are related to your recovery from your hospitalization 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 your care team followup instructions

name no admission date discharge date date of birth sex f service neurology allergies no known allergies adverse drug reactions attending chief complaint dizziness blurry vision major surgical or invasive procedure none history of present illness with pmh of microscopic polyangiitis diagnosed in multiple episodes of ischemic stroke in paroxysmal atrial fibrillation s p watchman device placement who presented as a direct admission from for vasculitis work up patient initially presented to on with dizziness starting am on while she was in the day room at at the time she had nausea double vision she went back to bed at am and slept for a while when she woke up for breakfast she felt dizzy and her gait was unsteady she fell to the ground and struck her head but did not lose consciousness she was brought to where she was vomiting ct head showed multiple chronic bilateral basal ganglia and corona radiata infarcts but no acute infarct patient was seen by dr on where she reported double vision with vertical images upon arrival to patient reported lightheadedness and blurred vision she states that she previously had double vision with vertical images but now her vision is blurred sometimes improved by closing one eye but not always she denies nausea per dr note she had an ischemic stroke in of the anterior limb of the left internal capsule she was initially started on aspirin which was stopped after pah in in she had acute infarct of the right putamen right corona radiata left inferior caudate a fib was found and she was placed on apixaban although she was noncompliant in she had acute infarcts of the left midbrain and anterior limb of the left internal capsule in she had diffuse bilateral subarachnoid hemorrhage cta showed mm aneurysm of the left terminal ica she underwent craniotomy and clipping of this aneurysm in she had acute right posterior periventricular and right frontal subcortical infarcts she was supposed to be taking a apixaban but she was noncompliant during the admission lovenox was given as a bridge to warfarin in she had watchman device placement she then had multiple small acute infarcts in the bilateral centrum semi ovale and corona radiata as well as a pontine infarct she was discharged on warfarin mg daily and aspirin in late she had left frontal infarcts and a right cerebellar infarct of varying ages in her warfarin was stopped as a tee in showed no thrombus in the left atrium or atrial appendage the plan was for aspirin daily indefinitely with repeat tee at months in year past medical history microscopic polyangiitis with lung and renal involvement stage ckd not on treatment currently as previously refused and recently felt to be quiescent by rheum af s p watchman device anticoagulation previously non compliant ischemic strokes x5 since most recently which prompted s p aneurysm clipping amyloid angiopathy innumerable cerebral microhemorrhages on mri pulmonary mac infection discovered in patient declined treatment severe large fibre sensorimotor polyneuropathy not sure if attributable to vasculitis unclear if advanced mononeuritis multiplex vs length dependent process social history family history mother had cancer of unknown type she has a son and a daughter she has been living at for several months she states that she had been hoping for discharge from the facility physical exam admission physcial exam general awake cooperative nad heent nc at no scleral icterus noted neck supple pulmonary normal work of breathing cardiac 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 language is fluent with intact repetition and comprehension normal prosody there were no paraphasic errors able to name chair hammock key glove but not cactus or feather able to read no dysarthria able to follow both midline and appendicular commands cranial nerves ii iii iv vi perrl to 2mm and brisk eomi without nystagmus vff to confrontation v facial sensation intact to light touch vii mild l nlff viii hearing intact to conversation 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 delt bic tri ecr fex io ip quad ham ta gas l r sensory no deficits to light touch pinprick vibration or proprioception throughout no extinction to dss reflexes bic tri pat ach l r r toe mute l toe upgoing coordination no intention tremor no dysmetria on fnf or hks bilaterally however patient does have slowed finger tapping on the left gait deferred discharge physical exam temp tm bp hr rr o2 sat o2 delivery ra general awake cooperative nad heent nc at no scleral icterus noted neck supple pulmonary normal work of breathing cardiac warm well perfused abdomen soft non distended extremities no edema skin no rashes or lesions noted neurologic mental status alert no confabulation this morning oriented to place states month is mild hoarseness improved from yesterday still w some dysarthria language is fluent with intact repetition and comprehension no prosody no paraphasic errors still effortful to get through moyb cranial nerves ii iii iv vi perrl to 2mm and brisk slight right hypertropia w intact eom no clear double vision though does note her vision is off on primary gaze v facial sensation intact to light touch vii mild l nlff viii hearing intact to finger rub 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 delt bic tri ecr fex io ip quad ham ta gas l r sensory no deficits to light touch pinprick vibration or proprioception throughout no extinction to dss reflexes bic tri pat ach l r coordination dysmetria with overshoot and past pointing on mirroring on left slower rapid movements of left hand compared to right slight ataxia on heel to shin on left gait deferred pertinent results labs 52pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 44am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 52pm blood glucose urean creat na k cl hco3 angap 44am blood glucose urean creat na k cl hco3 angap 58am blood alt ast alkphos totbili 52pm blood calcium phos mg 58am blood hba1c eag 58am blood triglyc hdl chol hd ldlcalc 52am cerebrospinal fluid csf tnc rbc polys macroph 52am cerebrospinal fluid csf totprot glucose pending labs 58am blood trep ab pnd 41am blood smooth pnd 41am blood sm antibody pnd 41am blood cardiolipin antibodies igg igm pnd 52am cerebrospinal fluid csf multiple sclerosis ms profile pnd imaging impression no interval change compared to mri from days ago no evidence of pachymeningeal enhancement left cerebellar hemisphere and right parietal white matter subacute infarctions appear unchanged chronic lacunar infarct in changes of chronic microangiopathy in the white matter unchanged multiple micro bleeds in a distribution most suggestive of amyloid angiopathy unchanged postoperative findings after left craniotomy and aneurysm clipping brief hospital course summary with pmh of microscopic polyangiitis diagnosed in inumerable episodes of ischemic stroke from paroxysmal atrial fibrillation s p watchman placement who presented as a direct admission from for vasculitis work up after initially presenting with dizziness nausea diplopia mri brain at showed acute infarct of the left paramedian cerebellum and subacute infarct right parietal corona radiata transitional issues pt had a dermatology biopsy of a few areas of her abdomen she had sutures placed and those will need to be removed by nursing or a physicians at her facility on or around two weeks following the biopsy please consider transition from aspirin 81mg to plavix 75mg given recurrent stroke on aspirin multiple labs pending at the time of discharge including treponemal ab anti cardiolipin antibodies antism antibodies pathology from skin biopsies ms panel follow up blood pressures amlodipine was started this admission for hypertension csf hold was done if there is a need for further csf studies pt ntoed to have a normocytic anemia on presentation please ensure patient has had adequate workup w age appropriate cancer screenings ie colonscopy please ensure that patient has a primary care appointment scheduled with her pcp ischemic infarcts in the past her strokes have largely been attributed to cardioembolic infarcts iso non compliance on ac however it seems unlikely that pt has had several strokes since from a cardioembolic source w a watchman present when there is no thrombus present was repeated this admission and did not show any watchman associated thrombus additionally she had tcds done to evaluate for possible ongoing microthrombi which were largely unremarkable differential at this time still includes recurrent cardioembolic emboli from atypical atrial cardiopathy though very atypical that pt has only had subcortical infarcts pt has undergone extensive workup in the past for etiology of her strokes including a hypercoaguable workup she had a recent conventional angiogram iso her sah which did not show evidence of a vasculitis at this point pt does not have active evidence of inflammation or systemic vasculitis she had a mildly elevated esr but a normal crp no new pulmonary symptoms her cr was close to her baseline and did not reveal a very active urinary sediment pr cr borderline elevated at rheumatology was consulted who overall did not believe her presentation was consistent w either as systemic or cns vasculitis additionally we repeated an lp which yielded a bland csf tnc rbc protein glu we repeated an mri w mprage sequences here which did not show evidence of vasculitis the differential for etiology of his strokes given largely subcortical distribution included intravascular lymphoma for which a skin biopsy was pursued results of which were pending at discharge additionally cadasil was considered given subcortical distribution of infarcts including a temporal lobe infarct that is in a somewhat atypical location for normal small vessel disease as well as her underlying cognitive deficits however notably the patient does not have migraine or a family hx of strokes given the diagnostic uncertainty a brain biopsy was carefully considered but after discussions with the patient this was deferred due to patient preference and relatively low yield of the test management of her recurrent strokes is difficult given her hx of sah and probable caa w evidence of microbleeds at this time she was discharged on aspirin 81mg and atorvastatin 40mg though switching from aspirin to plavix 75mg given recurrent strokes of unclear etiology could be a consideration in the future htn continued home carvedilol mg bid at home resumed home nifedipine hx of microscopic polyangiitis mac has been off immunosuppression without significant recurrence notably has a hx of mac colonization so would need treatment prior to further immunosuppression pt was evaluated by rheumatology while inpatient 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 x yes no if ldl reason not given statin medication allergy other reasons documented by physician advanced practice nurse physician physician apn pa or pharmacist ldl c less than mg dl 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 x yes no if no why not i e patient at baseline functional status discharged on statin therapy x yes no if ldl reason not given statin medication allergy other reasons documented by physician advanced practice nurse physician physician apn pa or pharmacist ldl c less than mg dl discharged on antithrombotic therapy x yes type x antiplatelet anticoagulation no discharged on oral anticoagulation for patients with atrial fibrillation flutter yes x no if no why not i e bleeding risk etc high bleeding risk w hx of caa has a watchman device in place n a medications on admission the preadmission medication list is accurate and complete acetaminophen mg po q4h prn pain mild fever atorvastatin mg po qpm carvedilol mg po bid aspirin mg po daily nifedipine extended release mg po daily discharge medications acetaminophen mg po q4h prn pain mild fever aspirin mg po daily atorvastatin mg po qpm carvedilol mg po bid nifedipine extended release mg po daily discharge disposition extended care facility diagnosis primary diagnosis acute ischemic stroke secondary diagnosis hypertension microscopic polyangitis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms you were hospitalized due to symptoms of unsteadiness resulting from an acute ischemic stroke a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot the brain is the part of your body that controls and directs all the other parts of your body so damage to the brain from being deprived of its blood supply can result in a variety of symptoms stroke can have many different causes so we assessed you for medical conditions that might raise your risk of having stroke in order to prevent future strokes we plan to modify those risk factors your risk factors are atrial fibrillation we did a number of tests to look for evidence of inflammation vasculitis or other causes of your stroke you had an echocardiogram multiple mris and a lumbar puncture of spinal tap you were also seen by the dermatology and rheumatology teams there were some labs still pending at the time you were discharged back to rehab and dr will follow these we are changing your medications as follows added amlodipine for blood pressure 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 no admission date discharge date date of birth sex f service medicine allergies no known allergies adverse drug reactions attending chief complaint hemoptysis eye redness major surgical or invasive procedure bronchoscopy with lavage history of present illness with h o mpa mpo ab positive with prior pulmonary involvement dah and renal involvement gn who presents with episodes of hemoptysis over the past day patient describes tablespoon amounts of blood x3 at home with 2x smaller amounts witnessed at she states this is similar to her intial presentation in she was transferred to for further work up and evaluation patient has also complained of mild ruq pain for the past several days on further questioning patient also reports ongoing cough for week productive of phlegm no fevers chills n v no recent weight loss no recent sick contacts however works as a with adolescents has been under increased stress this past week as she was just let go from her job on initial presentation to the ed vitals notable for ra exam notable for nad and normal pulmonary exam labs notable for normal chem wbc hgb crp of note she was admitted in with hemoptysis requiring intubation as well as renal failure she was found to have mpa based on high p anca titers and treated with high dose steroids cytoxan and plasma exchange she clinically and radiographically improved after this therapy she was tapered off prednisone and completed induction therapy for vasculitis in with cytoxan but declined maintenance therapy due to c f hair loss and financial difficulties she is followed by rheumatology here at her last visit in she was felt to be in remission but she was felt to be at high risk of relapse and was recommended to start azathioprine however she has not done this on arrival to the micu patient hd stable without complaint however requiring 3l o2 to maintain sats in high past medical history mpa with dah and glomerular nephritis lyme disease dagnosed in with prior sx including arthralgia inflammation behind the eye raynauds rashes and extremity pain weakness treated with erythromycin tetracycline in the past sp cva social history family history mother with history of unknown cancer physical exam physical exam on admission vitals afebrile 3l general alert oriented no acute distress heent l sclera injected inflamed no drainage mmm oropharynx clear neck supple jvp not elevated no lad lungs normal inspiratory effort initial crackles that cleared with cough otherwise no wheezes rales rhonchi cv regular rate and rhythm normal s1 s2 no murmurs rubs gallops abd soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema skin no rashes lesions noted neuro a ox3 moving all extremities with purpose physical exam on discharge vitals t bp 120s 60s p r o2 ra general alert oriented no acute distress heent l medial sclera interval improvement in erythema now normal appearing mmm oropharynx clear neck supple jvp not elevated no lad lungs clear to auscultation bilaterally faint bibasilar crackles no wheezes rales rhonchi cv rrr normal s1 s2 no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema skin no rashes neuro aaox3 perrl eomi moving all extremities sensation grossly in tact pertinent results labs on admission 45am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 45am blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 45am blood ptt 45am blood glucose urean creat na k cl hco3 angap 45am blood alt ast alkphos totbili 45am blood crp pertinent results 01pm blood cd19 cd19abs cd20 cd20abs 59pm blood anca positive ancattr 31am blood hbsag negative 01pm blood hbsab negative hbcab negative 01pm blood igg iga igm 45am blood c3 c4 30pm blood hiv ab negative 15pm blood sed rate test labs on discharge 55am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 55am blood plt 55am blood glucose urean creat na k cl hco3 angap 55am blood calcium phos mg micro am urine source final report urine culture final no growth am blood culture source venipuncture blood culture routine pending pm bronchoalveolar lavage bronchial lavage gram stain final per 1000x field polymorphonuclear leukocytes no microorganisms seen smear reviewed results confirmed respiratory culture final pseudomonas aeruginosa ml further workup on request only isolates are considered potential pathogens in amounts cfu ml workup requested by sensitivities mic expressed in mcg ml pseudomonas aeruginosa cefepime s ceftazidime s ciprofloxacin s gentamicin s meropenem s piperacillin tazo s tobramycin s legionella culture preliminary 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 direct smear no acid fast bacilli seen on concentrated smear acid fast culture preliminary pm rapid respiratory viral screen culture bronchial lavage 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 quantiferon test result reference range units quantiferon r tb gold indeterminate a negative results are indeterminate for response to esat tb7 and or cfp test antigens test result reference range units nil iu ml mitogen nil iu ml tb nil iu ml clinical studies procedures imaging ct chest diffuse areas of ground glass opacity in a peribronchovascular distribution could represent an inflammatory disorder an infectious process or diffuse alveolar hemorrhage depending on the clinical setting several more nodular opacities are seen bilaterally which may represent extension of the underlying process described above however short interval follow up chest ct after symptoms have resolved is recommended to ensure resolution bronch lavage 4ml bloody fluid negative for malignant cells pulmonary macrophages epithelial cells some containing hemosiderin brief hospital course ms is a y o f w anca associated vasculitis mpa status post induction therapy with six months of oral cyclophosphamide and prednisone and no maintenance since completing induction therapy in who was admitted for hemoptysis and eye redness mpa c b dah glomerulonephritis and episcleritis patient initially presented to the hospital after coughing up tablespoon amounts of blood x3 at home with 2x smaller amounts witnessed at she states this is similar to her last presentation in with mpa c b dah flare she was transferred to for further work up and evaluation in terms of her mpa treatment history patient is status post induction therapy with six months of oral cyclophosphamide and prednisone but no maintenance since completing induction therapy in she reports that she decided against maintenance therapy due to concern for hair loss and cost of the medication here at patient was diagnosed with mpa c b diffuse alveolar hemorrhage medial episcleritis and glomerulonephritis patient underwent a bronchoscopy procedure by ip which visualized large blood cultures for ml pseudomonas see problem below but no cells concerning for malignancy the bleeding spontaneously stopped and her hgb was stable at further labs were notable for anca titer crp and normal immunoglobulin levels she also had cr from baseline of with microscopy positive for rbcs and acanthocytes diagnostic of glomerulonephritis patient was seen by her outpatient nephrologist dr who recommended continuing treatment per rheumatology recommendations patient was evaluated by ophthalmology who also deferred treatment to rheumatology for management the rheumatology consult team recommended days of pulse methylpred followed by initiation of prednisone 60mg daily to be tapered in the outpatient setting she will take bactrim ss daily for pcp additionally it was recommended that patient start qweekly rituxan therapy for weeks day due to patient having an indeterminate quantiferon gold test in the setting of being on prednisone the id team recommended starting concurrent inh for months however due to concern for side effects i e neuropathy patient declined inh treatment a thorough discussion was held with the patient regarding the risk of developing a life threatening active tuberculosis infection and she fully understood these risks in making her decision patient will follow up with her primary care rheumatology and nephrology physicians as outpatient at the time of discharge patient was breathing comfortably on room air with complete resolution of her eye symptoms and had a cr of pseudomonas colonization patient grew pseudomonas ml from bronch lavage per id likely just colonization and no need for any treatment due to it not being pathogenic it was recommended that if patient develops a fever or symptoms of pneumonia in the outpatient setting that there be a low threshold to treat hep b non immune patient has a negative hbs ag and ab per patient she has never been immunized she has initiated rituxan therapy and would benefit from outpatient hep b vaccination anemia patient has a history of anemia with hgb during this admission she was anemic to but the h h remained stable the new drop was likely in the setting of hemoptysis from diffuse alveolar hemorrhage she did not need any transfusions due to blood count stability please follow up regarding her anemia in the outpatient setting ruq pain at the time of admission patient endorsed having some ruq pain this quickly resolved within hours and was determined by the icu team to be secondary to vigorous coughing patient did not have any other abdominal pain for the remainder of her hospitalization transitional issues follow up on her mpa c b dah and glomerulonephritis patient will have qweekly rituxan treatment x 4weeks week was done inpatient beginning patient also discharged on mg prednisone daily to be tapered by rheumatology at outpatient follow up and bactrim for pcp please obtain repeat chemistry panel on during outpatient appointment follow up regarding her hep b non immune status patient would benefit from vaccination please note per id due to indeterminate quant gold result while on steroids obscures reliability of test result patient should be on inh x mo however after a thorough discussion with her patient decided to decline while fully understanding the risks of developing an active tb infection while on rituxan please follow up and assess her interest in starting inh as outpatient ct chest demonstrated several more nodular opacities are seen bilaterally which may represent extension of the underlying process dah please obtain repeat ct in months per radiology follow up on final blood culture data pending at time of discharge please note patient grew pseudomonas ml from bronch lavage per id likely just colonization and no need for any treatment if develops fever in outpatient to have low threshold for treatment code full code confirmed contact medications on admission none discharge medications prednisone mg po daily rx prednisone mg tablet s by mouth daily disp tablet refills sulfameth trimethoprim ss tab po daily rx sulfamethoxazole trimethoprim bactrim mg mg tablet s by mouth once daily disp tablet refills vitamin d unit po daily rx ergocalciferol vitamin d2 unit tablet s by mouth once daily disp tablet refills discharge disposition home discharge diagnosis primary diagnoses microscopic polyangiitis c b diffuse alveolar hemorrhage and glomerulonephritis hep b non immune secondary diagnoses anemia discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms it was a pleasure to care for you at you were hospitalized due to bleeding from your lung as well as inflammation of your eye and kidneys due to this you were in the intensive care unit and underwent a bronchoscopy procedure which confirmed that you were bleeding from your lung your bleeding stopped on its own and you did not need any blood transfusions the ophthalmology doctor evaluated your eye and recommended treatment based on rheumatology recommendations the rheumatology doctors and recommended treating you with days of iv steroids followed by continuing prednisone 60mg daily since beginning steroid treatment your eye redness improved and you had no other episodes of bleeding you will follow up with dr in the outpatient setting and she will start to taper your prednisone at that time you will also need to take an antibiotic called bactrim every day to prevent infections while you take the steroids while you were here it was also recommended that you initiate rituxan therapy to better control your microscopic polyangiitis this was discussed with the rheumatology doctors infectious disease doctors dr all agreed your quantiferon gold test result was indeterminate because of this the infectious disease doctors recommended that start isoniazid while you are on the rituxan you elected to not take this medication due to potential side effects we discussed the risks of potentially developing a life threatening active tuberculosis infection and you understood these considerations in reaching your decision please take all your medications as instructed and follow up with your outpatient doctors at the listed below if you develop any fever chills shortness of breath or acute weight loss please present to the nearest emergency room it was a pleasure to care for you while you were here sincerely your care team followup instructions

name no admission date discharge date date of birth sex f service medicine allergies no known allergies adverse drug reactions attending chief complaint left sided weakness major surgical or invasive procedure bronchoscopy history of present illness ms is a year old woman with a pertinent past medical history of microscopia polyangiitis panca mpo presented as diffuse alveolar hemorrhages and glomerulonephritis in and hx tia and cva last symptomatic stroke who presented on with left sided weakness to and was transferred today to for further management ms was in her normal state of health she lives alone with her dog and is an unemployed until am on when she awoke from bed and noted that she was weak on her left side she found it difficult to get out of bed when she managed to stand she felt that her left leg was wobbly and she could not walk to get to the bathroom she says that at am that morning she woke up and used the bathroom before returning back to bed and she did not perceive any symptoms at that time she decided to call an ambulance who transported her to discharge summary patient was noted to be tachycardic bpm tachypneic rr23 and hypertensive saturating well on room air head ct was done which demonstrated no acute pathology chest film was done which showed no infiltrate code stroke was not called because she was out of the window but neurology was contacted nihss was for mild ataxia weakness of left arm and subjective numbness of the left arm she was given mg of oral aspirin per patient she was able to walk yesterday with a walker patient does not use one at baseline but she still felt wobbly though less so than the day before today she feels like she is regaining her strength back but she is not at her baseline her prior stroke was in she presented to with l nlff and l ue weakness of note had brief episode of diplopia months before mri at showed acute infarction in the right putamen corona radiata and in the left inferior caudate head she had been started on aspirin during her prior stroke but it had been discontinued after diffuse alveolar hemorrhage in she notes a cough which has been present for months she does not currently have health insurance secondary to her unemployment and therefore has not had a health maintenace visit in year and takes no medications she has a rheumatologist here at the she attests to last having been seen by rheumatology in early after her last vasculitis flare in which was treated with days of pulse methylprednisolone and several weeks of rituximab per patient the course was stopped due to concern for infection due to immunosuppression on ros the pt endorses worsening sob she does not note palpitations but says that her hr has been faster than usual she denies headache loss of vision blurred vision diplopia dysarthria dysphagia or vertigo denies difficulties producing or comprehending speech denies numbness parasthesias no bowel or bladder incontinence or retention past medical history mpa panca mpo vasculitis with diffuse alveolar hemorrhage and glomerulonephritis diagnosed in initially treated with steroids plasmapheresis and months of cyslophosphamide patient refused to start aza that rheumatology had recommended after cytoxan last flare in cva on presented to with l nlff and l ue weakness of note had brief episode of diplopia months before mri at showed acute infarction in the right putamen corona radiata and in the left inferior caudate head lyme disease possible per notes diagnosed in symptomatic episodes including arthralgias raynaud s extremity pain and weakness treated with multiple courses of erythromycin tetracycline in the past over the course of years with a lyme specialist however it is possible that most of these symptoms were manifestations of her yet undiagnosed vasculitis social history family history mother with unknown cancer physical exam admission physical exam vitals t p r bp sao2 general awake cooperative nad heent nc at no scleral icterus noted mmm no lesions noted in oropharynx pulmonary expiratory wheezes noted bilaterally patient has productive cough cardiac tachycardic nsr on telemetry warm well perfused extremities no edema skin microvascular rash notes on baseline from vasculitis per patient 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 speech was not dysarthric able to follow both midline and appendicular commands pt was able to register objects and recall at minutes there was no evidence of apraxia or neglect cranial nerves ii iii iv vi perrl to 2mm and brisk eomi without nystagmus normal saccades vff to confrontation v facial sensation intact to light touch vii no facial droop facial musculature symmetric viii could not hear finger rub bilaterally ix x palate elevates symmetrically xi strength in trapezii bilaterally xii tongue protrudes in midline with good excursions motor normal bulk tone throughout no pronator drift bilaterally no adventitious movements such as tremor noted no asterixis noted delt bic tri wre fe ip quad ham ta l r sensory no deficits to light touch cold sensation vibratory sense proprioception throughout patchy difference on pinprick on lower extremities bilaterally romberg absent dtrs tri pat ach l r plantar response was flexor on right and extensor on left coordination no intention tremor normal finger tap bilaterally no dysmetria on fnf but dysmetria noted on left hks no rebound ataxia gait some hesitation narrow based spastic discharge physical exam vs po ra gen pleasant nad sitting up in bed conversant heent sclerae anicteric mmm no lesions or thrush tongue deviated slightly towards the r neck supple cv rrr normal s1 s2 no murmurs pulm prominent crackles throughout b l heard both posteriorly and anteriorily decreased breath bilaterally occasionally coughing during interview abdm nd bowel sounds soft nontender msk no joint swelling or erythema extr wwp no edema skin no rash on lower extremities neuro aox3 cn intact strength and symmetric in upper and lower extremities minimal ataxia on l with heel to shin pertinent results laboratory data admission labs ptt glucose urean creat na k cl hco3 angap alt ast ld ldh ck cpk alkphos totbili totprot albumin globuln calcium phos cholest hba1c triglyc hdl ldl tsh crp ptt glucose urean creat na k cl hco3 angap crp esr hbsag neg hbsab neg hbcab neg hcv neg hiv neg b2 glycoprotein i igg ab reference smu b2 glycoprotein i igm ab reference smu b2 glycoprotein i iga ab reference smu cardiolipin ab pnd quant tb gold negative discharge labs 35am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 35am blood glucose urean creat na k cl hco3 angap 35am blood calcium phos mg imaging studies non contrast ct of head no acute intracranial process no infarct or hemorrhage mri w o contrast restricted diffusion of posterior limb of r internal capsule with t2 flair hyperintensity compatible with a late acute to early subacute infarction probable late acute infarct of posterior r frontal lobe punctate lobar foci microbleeds probable chronic hemorrhagic infarcts in l external capsule and non hemorrhagic chronic infarcts in basal ganglia echocardiogram normal lvef no wall motion abnormalities trivial physiologic mitral regurgitation chest pa lat there is essentially no change compared to the examination from days prior heart size is top normal with unfolding of the thoracic aorta and subtle knob calcifications there is mild to moderate right greater than left pleuroparenchymal scarring increased pulmonary interstitial markings appear similar to the prior examination suggesting a background interstitial lung disease otherwise no new consolidation is seen there is no effusion pneumothorax there is no acute osseous abnormality cta chest no evidence of pulmonary embolism or acute aortic abnormality nonspecific diffuse multifocal nodular and ground glass opacities favor an infectious or inflammatory process the ground glass component is nonspecific though could be partially explained by mild diffuse alveolar hemorrhage given the patient s history diffuse cylindrical bronchiectasis and bronchial wall thickening has progressed since small pericardial effusion pulmonary nodules measuring up to mm in mean diameter for incidentally detected multiple solid pulmonary nodules bigger than 8mm a ct follow up in to months is recommended in a low risk patient with an optional ct follow up in to months in a high risk patient both a ct follow up in to months and in to months is recommended microbiology pm sputum source expectorated gram stain final pmns and epithelial cells 100x field per 1000x field multiple organisms consistent with oropharyngeal flora quality of specimen cannot be assessed respiratory culture preliminary moderate growth commensal respiratory flora acid fast smear final no acid fast bacilli seen on concentrated smear acid fast culture preliminary am sputum site expectorated source expectorated gram stain final pmns and epithelial cells 100x field per 1000x field gram negative rod s per 1000x field multiple organisms consistent with oropharyngeal flora respiratory culture preliminary moderate growth commensal respiratory flora acid fast smear final no acid fast bacilli seen on concentrated smear acid fast culture preliminary am bronchoalveolar lavage right lower lobe gram stain final per 1000x field polymorphonuclear leukocytes no microorganisms seen respiratory culture preliminary results pending legionella culture preliminary no legionella isolated potassium hydroxide preparation final test cancelled by laboratory patient credited this is a low yield procedure based on our in house studies if pulmonary histoplasmosis coccidioidomycosis blastomycosis aspergillosis or mucormycosis is strongly suspected contact the microbiology laboratory immunofluorescent test for pneumocystis jirovecii carinii final specimen combined with sample 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 am bronchoalveolar lavage right lower lobe viral culture r o cytomegalovirus preliminary specimen combined with sample no cytomegalovirus cmv isolated cytomegalovirus early antigen test shell vial method preliminary am rapid respiratory viral screen culture right lower lobe respiratory viral culture preliminary specimen combined with sample 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 specimen combined with sample bronchoscopy airways were mildly erythematous diffusely there were purulent secretions in the right middle and lower lobes and left upper lobe the right upper middle and lower lobe subsegments were inspected without evidence of mass mucosal lesions or other abnormality the left upper and lower lobe subsegments were inspected without evidence of mass mucosal lesions or other abnormality serial bronchoalveolar lavage was performed in the right upper lobe apicoposterior segment with return to clear fluid on the first lavage and slightly pink fluid on the second findings which are not suggestive of alveolar hemorrhage though do not definitively exclude it bronchoalveolar lavage was performed in the right lower lobe with return of pink fluid no areas of dried blood or previous stigmata of bleeding or alveolar hemorrhage were noted brief hospital course with a history of microscopic polyangiitis vasculitis panca mpo cva and several tias who presented to on with l sided weakness found to have a subacute stroke transferred to to neurology service found to have pafib with rvr as well as bronchiectasis and multifocal opacities on ct chest transferred to medicine for further management subacute stroke posterior limb of l internal capsule patient initially presented tp with left sided weakness transferred to for further stroke work up and rheumatology co management patient has a history of multifocal small vessel strokes back in asa had been started in after her stroke but discontinued in the setting of diffuse alveolar hemorrhage presentation in on presentation here she had mild weakness on the left ue and and extensor plantar response on left no facial weakness or cn involvement on mri done at she found to have restricted diffusion of the posterior limb of left internal capsule consistent with new acute stroke and l parietal subacute stroke review of imaging showed the locations of prior chronic infarcts no additional microhemorrhages were noted on gradient echo regarding the etiology of her stroke the patient as found to have occasional episodes of afib with rvr new diagnosis for her suggesting a cardioembolic source osh echo was neg for structural abnormalities although patient has history of microscopic polyangitis less likely due to cns vasculitis because per rheumatology would only be a concern if patient had extremely active rheumatologic process which is not her presentation as her renal function is close to her baseline furthermore there was no clear beading vascular change on cta to suggest vasculitis stroke workup was otherwise negative cta did not show significant atherosclerosis or large or medium vessel disease patient does not have notable metabolic risk factors regarding her course l sided weakness and ataxia with significant improvement here patient worked with physical therapy and discharged to home with outpatient started on apixaban for af after multiple discussions of risks and benefits patient was accidentally discharged on ongoing asa as well this was an error as patient has no indication for asa if she is on apixaban multiple attempts made to contact patient by phone without response will continue attempting contact i anticipate that the patient is probably not taking either of these medications due to her reluctance also attempted to start patient on atorvastatin on discharge but patient was not amenable to statin treatment hypercoagulability workup apls testing pending at the time of discharge b2 glycoprotein anticardiolipin lupus anticoagulant paroxysmal afib with rvr patient had two episodes of acute tachycardia and felt palpitations tele demonstrated irregular rhythm with no distinguishable p waves and hr to 160s c f afib with rvr went back into sinus rhythm per patient no prior history of afib echo negative for valvular disease cha2ds2vasc stroke gender htn of putting her at risk per yr renal stroke bleed of stroke risk per year patient initially very hesitant to start anticoagulation but eventually was amenable to starting apixaban also started on metoprolol asa should be stopped have attempted to reach patient by phone without success chronic cough and shortness of breath patient has had a cough productive of white sputum for months which she states has been improving she has also had sob for the past weeks negative patient has not been on immunosupression since last flare in when she presented with hemoptysis treated with pulse methylpred and rituximab stopped when bronch sputum cx grew and psuedomonas and patient refused triple abx therapy at the time patient very hesitant to use abx use after accruing ses from chronic use of erythromycin tetracyclines for putative lyme id was consulted to evaluate infx status especially given untreated and pseudomonas found to have extensive bronchiectasis and multifocal opacities on ct chest as well as esr given concern for dah iso active mpa vasculitis flair bronchoscopy was performed on which demonstrated purulent secretions in the right middle and lower lobes but no strong evidence of alveolar hemorrhage thus etiology of cough sputum likely thought to be secondary to infection with either and or pseudomonas less likely due to vasculititis because per rheumatology her pulmonary presentation is not consistent with sequelae of microscopic polyangitis prelim cultures bal sputum x2 with oral flora and gnrs still pending at time of discharge respiratory viral screen negative quantiferon gold negative hiv hepb hepc negative given stable respiratory function patient discharged with plan for f u with rheum and id regarding need for abx vs immunosuppression e g rituximab per pulm recs patient was recommended treatment for preseumed cap but declined antibiotics at this time patient determined to have capacity for this and other decisions indicating clear understanding of the risks and benefits in the setting of rational thought processes renal impairment anca vasculitis admitted with cr of baseline in history of mpa presenting with glomerulonephritis in has not had renal biopsy in the past and wast lost to f u with rheum and nephron clinics after second flare kidney function has been stable over the years with cr and proteinuria at baseline sediment showing acanthocytes and dysmorphic red cells could be c f active vasculitis but finding can be seen in chronic anca patient w o flare renal biopsy would not be clinically beneficial at this time plan for f u with outpatient nephrologist dr anca titer to assess disease activity pending at time of discharge core measures nutrition regular vte prophylaxis apixaban code status fc confirmed w patient health care proxy emergency contact son consulting services renal id pulm neuro rheum transitional issues pt will have follow up with id regarding treatment of active pulmonary infections specifically ntmb and will require treatment prior to initiation of immunosuppression pt started on apixaban for ongoing anticoagulation given her history of atrial fibrillation and stroke pt will need to establish a new primary care doctor in the next week when her insurance coverage is more stable and we discussed the importance of this with her prior to discharge continue to attempt contact with patient to instruct her not to take asa while taking apixaban medications on admission no medications discharge medications apixaban mg po bid rx apixaban eliquis mg tablet s by mouth twice daily disp tablet refills aspirin mg po daily atorvastatin mg po qpm rx atorvastatin mg tablet s by mouth nightly disp tablet refills metoprolol succinate xl mg po daily rx metoprolol succinate mg tablet s by mouth daily disp tablet refills outpatient physical therapy evaluate and treatment weeks 3x wk icd j47 bronchiectasis uncomplicated discharge disposition home discharge diagnosis subacute stroke posterior limb of l internal capsule paroxysmal afib with rvr microscopic polyangiitis vasculitis 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 why you came to the hospital you were having weakness in your left leg you had also been having a cough for the past few months you originally went to and you were transferred to for further care what we did in the hospital you had an mri of your brain which showed that you had a stroke on the right side of your brain you had a ct scan of your lungs which showed a significant amount of inflammation in your lungs you had a bronchoscopy which did not show any bleeding in your lungs but did show inflammation we took samples of the fluid in your lungs to check for an infection what you need to do when you get home please take the eliquis metoprolol and atorvastatin as prescribed please schedule an appointment to work with a physical therapist we have given you a prescription you can bring to any physical therapist please follow up with dr infectious disease dr kidney and dr rheumatology you will need to call to make a new primary care appointment followup instructions

name no admission date discharge date date of birth sex f service neurology allergies no known allergies adverse drug reactions attending chief complaint double vision dizziness gait unsteadiness major surgical or invasive procedure lumbar puncture history of present illness neurology stroke admission note bid cc double vision transfer from hpi woman previously seen here on the stroke service in with a history of microscopic polyangiitis mpo pr3 complicated by dah glomerulonephritis and episcleritis who presented to on with one day of horizontal diplopia days prior to admission she was driving back from dinner and noticed that her vision changed she said it was difficult to describe but it was hard to tell where the edge of the car was and where the edge of the rode was she awoke on the morning of with a mild headache when she stood up to walk she noted room spinning and needed to use the guard rail to stay steady she did not have any other symptoms at that time she looked in the mirror and noted that her left eye appeared abnormal she noted double vision horizontal that has been persistent but now is improving per patient she was admitted to the medicine service with neurology consult no tpa was given that symptom onset was unknown while admitted she underwent a cta head and neck final read pending without lvo she had an mri w o contrast today which showed a subacute infarct in the midbrain on the l of the nerve nucleus she also was shown to have few possible microhemorrhages on swi sequence neurology suggested 81mg aspirin and transfer to neuro for work up of possible cns vasculitis and rheumatology consult patient reports that she has not been taking apixaban or any of her other prescribed medications which was started in for paroxysmal afib regarding her prior history the patient was initially diagnosed with mpa in initially treated with steroids and then cyclophosphamide she was suggested to start aza but patient did not want this medication she did a few courses of cytoxan in she was re admitted in for recurrent dah and episcleritis she was given methylprednisone for this followed on prednisone she was then started on rituximab but later bronch was done that was more suggestive of infection rather than dah stroke history first stroke in presented to in with l nlff and lue weakness mri showed an acute infarction in the r putamen corona radiate and l inferior caudate head she was started on aspirin 81mg at this time but it was later discontinued in after she developed diffuse alveolar hemorrhage presented in with l sided weakness to and transferred to on mri she was found to have a new infarct of the l internal capsule and a l parietal subacute stroke she was subsequently found on admission here to have paroxysmal a fib with rvr and was started on apixaban etiology of stroke was thought to be due to afib and less likely due to cns vasculitis as she was not having an active vasculitis flare systemically furthermore there was no beading on cta lp was deferred at this time on neuro ros the pt endorses mild horizontal diplopia when looking to the right she says it has improved greatly since it started she also endorses difficulty walking but can t say if she felt unsteady or if it is due to the difficulty seeing she denies headache loss of vision blurred vision dysarthria dysphagia lightheadedness vertigo tinnitus or hearing difficulty denies difficulties producing or comprehending speech denies focal weakness numbness parasthesiae no bowel or bladder incontinence or retention denies difficulty with gait on general review of systems the 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 or joint pain pmh microscopic polyangiitis diffuse alveolar hemorrhage and glomerulonephritis chronic kidney disease paroxysmal atrial fibrllation history of subacute stroke posterior limb of l internal capsule history of multifocal small vessel strokes diffuse alveolar hemorrhage lyme disease possible per notes diagnosed in symptomatic episodes including arthralgias raynaud s extremity pain and weakness treated with multiple courses of erythromycin tetracycline in the past over the course of years with a lyme specialist however it is possible that most of these symptoms were manifestations of her yet undiagnosed vasculitis home medications takes no home medications other than protonics allergies no allergies social hx lives with her son who is in she has been doing temp work used to be a sw and just did a few months at as psych sw does all her own adls denies any smoking drinks a year denies any other drugs 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 hx reviewed and found to be not relevant to this illness reason for hospitalization past medical history microscopic polyangiitis with previous complications of diffuse alveolar hemorrhage and glomerulonephritis initially diagnosed in prior treatments including steroids plasmapheresis cyclophosphamide prior stroke presented with l nlff and l ue weakness mri at showed acute infarction in the right putamen corona radiata and in the left inferior caudate head paroxysmal atrial fibrillation previously non compliant on oral anticoagulation hypertension previously non compliant on anti hypertensives social history family history mother with unknown cancer physical exam initial physical examination 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 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 able to relate history without difficulty attentive language is fluent with intact repetition and comprehension normal prosody there were no paraphasic errors pt was able to name both high and low frequency objects able to read without difficulty speech was not dysarthric able to follow both midline and appendicular commands cranial nerves perrl to 2mm and brisk double vision with rightward gaze unable to say which image went away with covering eyes says two fingers on side by side overlapping left eye does not fully adduct nystagmus with right ward gaze facial sensation intact to light touch face is symmetric other than mild ptosis on left baseline per patient hearing intact to finger rub bilaterally palate elevates symmetrically strength in trapezii bilaterally tongue protrudes in midline with good excursions motor normal bulk tone throughout no pronator drift bilaterally no adventitious movements such as tremor noted no asterixis noted no rebound delt bic tri wre fe ip quad ham ta l r sensory no deficits to light touch pinprick throughout no extinction to dss dtrs tri pat ach l r plantar response was flexor on right extensor on left coordination no intention tremor normal finger tap bilaterally no dysmetria on fnf or hks bilaterally discharge physical examination mild horizontal diplopia when looking to the right unable to say which image goes away when closing eyes she says its two images on top of each other cannot fully adduct left eye mild ptosis on left baseline per patient rest of exam is normal pertinent results 58pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 35am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 58pm blood plt 58pm blood ptt 35am blood plt 58pm blood glucose urean creat na k cl hco3 angap 35am blood glucose urean creat na k cl hco3 angap 25am blood alt ast ld ldh alkphos totbili 58pm blood calcium phos mg 35am blood calcium phos mg 25am blood hba1c eag 25am blood triglyc hdl chol hd ldlcalc 25am blood albumin cholest 25am blood tsh 10pm blood anca pnd 25am blood crp 25am blood sed rate test cta at impression no acute intracranial abnormality by unenhanced head ct very limited cta head and neck due to poor opacification of the arterial vessels as above within these confines there are areas of mild narrowing of the bilateral intracranial icas due to calcified plaque otherwise the remainder of the circle vasculature appears patent without stenosis occlusion or aneurysm patent bilateral cervical and vertebral arteries with areas of poor visualization of the thoracic inlet skullbase as above no discernible ica stenosis by nascet criteria chronic intracranial findings include global parenchymal volume loss and moderate changes of chronic white matter microangiopathy small chronic lacunar infarcts in the left internal capsule and right corona radiata seen on prior mr examinations diffuse pulmonary interstitial abnormality as described above similar to prior exams other incidental findings as above labs wbc rbc protein glucose echo trans thoracic ef no evidence of intracardiac shunt no evidence of thrombus mri brain w wo contrast impression redemonstration of acute or early subacute infarct in the left midbrain left internal capsule no evidence of hemorrhagic transformation multiple micro bleeds suggesting amyloid angiopathy no abnormal contrast enhancement multiple chronic infarctions brief hospital course ms is a year old right handed female with past medical history significant for prior stroke hypertension paroxysmal atrial fibrillation and microscopic polyangiitis at baseline she lives independently although her family states that she has been increasingly withdrawn over the past several months she is also admittedly non compliant with medications including anti hypertensives and oral anticoagulation during this admission she was found to have an acute infarction of the left midbrain not treated with iv tpa or mechanical thrombectomy she had a relatively hospital course and was discharged home in stable condition acute ischemic infarction exam is notable for horizontal binocular diplopia and ataxia as a consequence of an acute ischemic infarction involving the left midbrain and anterior limb of the left internal capsule iv tpa was not provided as the patient had an unknown last known well time mechanical thrombectomy was not offered as she did not have an lvo etiology is most consistent with cardioembolic from known atrial fibrillation although small vessel ischemic disease is still a possibility given her poorly controlled hypertension during this admission cta head neck was negative for a large vessel occlusion transthoracic echocardiogram was unremarkable risk factor labs showed hba1c and ldl she had an mri brain at the outside hospital without contrast which was significant for the acute strokes while admitted at she had an mri with contrast that showed several microhemorrhages on the swi sequence as well as a small enhancing area near the interpeduncular cistern the enhancing lesion was reviewed with the radiologist who stated that the appearance was most consistent with a draining vein rather than an inflammatory lesion given her history of rheumatologic disease an lp was performed to exclude an inflammatory lesion as the etiology for her infarctions the csf was not consistent with an ongoing cns vasculitis lp labs wbc rbcs protein normal glucose rheumatology did not suggest any changes to the plan at this time although they requested a serum anca and it is pending she was evaluated by who recommended discharge to home at time of discharge we recommended that she resume her oral anticoagulation and restart anti hypertensive medications we also added a statin for secondary stroke prevention we arranged follow up with a new pcp as she did not like her prior pcp and this may have been contributing to some of her medication non compliance she will follow up with neurology to continue to monitor and modify her vascular risk factors at time of discharge her symptoms were subjectively objectively improving with the patient only reporting shadow images in certain directions of gaze as well as a mild left upper lower extremity ataxia atrial fibrillation chronic was not compliant with oral anticoagulation prior to admission her apixaban was restarted she was monitored on telemetry this admission and a tte was performed both of which were unremarkable she was started on carvedilol 125mg bid for rate control microscopic polyangiitis chronic the patient was initially diagnosed with mpa mpo pr3 in and initially treated with steroids and then cyclophosphamide she was suggested to start aza but patient did not want this medication she did a few courses of cytoxan in she was re admitted in for recurrent diffuse alveolar hemorrhage and episcleritis she was given methylprednisone for this followed on prednisone she was then started on rituximab but later bronch was done that was more suggestive of infection rather than dah she also had glomerulonephritis with ckd we did not find a relation to her acute neurologic issues this admission ex cns vasculitis rheumatology did not make any new recommendations although serum anca is still pending ckd in context of glomerulonephritis chronic baseline creatinine was at baseline this admission elevated tsh incidental finding of low tsh this admission t4 needs to be followed up on mycobacterium on bal in rheumatology recommends that patient sees i d in clinic in the near future for bal in important as patient may need immunosuppressive therapy in the future psych behavioral assessment family endorses recent history of depressed mood and decreased motivation anhedonia this may be a contributor to her medication non compliance as well a mocha was performed and she scored a suggesting no cognitive decline at this time social work was involved and this can continue to be monitored by her pcp on an outpatient basis she also does not have part d of medicare and social work was able to show her how to set that up and in the meantime get cost coverage for apixaban transitional issues continued monitoring of vascular risk factors htn afib continued monitoring of medication compliance and application for part d of medicare will need follow up on serum anca and serum t4 will need follow up on remainder of lp labs pending at discharge hsv ace ms panel eventually require outpatient evaluation by psychiatry psychology for depressed mood and social withdrawal will need her ability to drive monitored at the time of discharge we recommended not driving for a period of time following her stroke as she was still experiencing some diplopia pcp also to follow up that patient had bal for mycobacterium in rheumatology recommends that patient sees id sometime in the near future in case she needs immunosuppression in the future pcp consider hearing test as patient exhibits some hearing loss on exam 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 c less than mg dl smoking cessation counseling given yes no reason x non smoker unable to participate stroke education personal modifiable risk factors how to activate ems for stroke stroke warning signs and symptoms prescribed medications need for followup given verbally or written x yes no assessment for rehabilitation or rehab services considered x yes no if no why not i e patient at baseline functional status discharged on statin therapy x yes no if ldl reason not given statin medication allergy other reasons documented by physician advanced practice nurse physician physician apn pa or pharmacist ldl c less than mg dl discharged on antithrombotic therapy x yes type antiplatelet x anticoagulation no discharged on oral anticoagulation for patients with atrial fibrillation flutter x yes no if no why not i e bleeding risk etc n a medications on admission the preadmission medication list is accurate and complete probiotic b breve l acid l rham s thermo br l acidophilus l rhamnosus br l rhamn a bifido s thermop br lactobacillus acidophilus br lactobacillus comb no br lactobacillus combination no br lactobacillus combo no billion cell oral daily discharge medications apixaban mg po bid rx apixaban eliquis mg tablet s by mouth twice per day disp tablet refills atorvastatin mg po qpm rx atorvastatin mg tablet s by mouth nightly disp tablet refills carvedilol mg po bid rx carvedilol mg tablet s by mouth twice per day disp tablet refills probiotic b breve l acid l rham s thermo br l acidophilus l rhamnosus br l rhamn a bifido s thermop br lactobacillus acidophilus br lactobacillus comb no br lactobacillus combination no br lactobacillus combo no billion cell oral daily discharge disposition home with service facility discharge diagnosis acute ischemic stroke discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms you were hospitalized due to symptoms of dizziness and double vision resulting from an acute ischemic stroke a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot the brain is the part of your body that controls and directs all the other parts of your body so damage to the brain from being deprived of its blood supply can result in a variety of symptoms stroke can have many different causes so we assessed you for medical conditions that might raise your risk of having stroke in order to prevent future strokes we plan to modify those risk factors your risk factors are prior stroke hypertension paroxysmal atrial fibrillation we are changing your medications as follows start apixaban start carvedilol start atorvastatin please follow up with neurology and your primary care physician stroke physician dr at primary care physician dr pcp at building floor central suite the rheumatologist that saw you in the hospital will call you with an appointment with your previous rheumatologist for your information here is the contact information for the integrated medicine clinic we did not create an appointment if you are interested for more information please call or e mail 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 no admission date discharge date date of birth sex f service neurosurgery allergies no known allergies adverse drug reactions attending chief complaint headache major surgical or invasive procedure diagnostic angiogram left craniotomy for clipping of left ica bifurcation aneurysm history of present illness is a female on asa last taken being worked up for cns vasculitis and recent admission for embolic stroke secondary to a fib who presents today for suspected aneurysmal sah patient awoke with whol this morning at 3am she denies having any neurologic symptoms visual changes or at this time she called ems who took her to where a showed diffuse left sided sah she was transported to the via life flight and neurosurgery was consulted to evaluate and determine the need for surgical intervention past medical history microscopic polyangiitis chronic kidney disease paroxysmal atrial fibrillation acute ischemic stroke multiple in history of subacute stroke history of multifocal small vessel strokes diffuse alveolar hemorrhage suspected lyme disease has been seen by a lyme specialist and has been treated with multiple courses of erythromycin tetracycline over years social history family history patient does not believe there is a family history of aneurysms mother with unknown cancer physical exam on admission and grade i asymptomatic mild headache slight nuchal rigidity x grade ii moderate to severe headache nuchal rigidity no neurological deficit other than cranial nerve palsy grade iii drowsiness confusion mild focal neurological deficit grade iv stupor moderate severe hemiparesis grade v coma decerebrate posturing grade no hemorrhage evident subarachnoid hemorrhage less than 1mm thick x subarachnoid hemorrhage more than 1mm thick subarachnoid hemorrhage of any thickness with ivh or parenchymal extension wfns sah grading scale x grade i gcs no motor deficit grade ii gcs no motor deficit grade iii gcs with motor deficit grade iv gcs with or without motor deficit grade v gcs with or without motor deficit coma scale intubated x not intubated eye opening does not open eyes opens eyes to painful stimuli opens eyes to voice x opens eyes spontaneously verbal makes no sounds incomprehensible sounds inappropriate words confused disoriented x oriented motor no movement extension to painful stimuli decerebrate response abnormal flexion to painful stimuli decorticate response flexion withdrawal to painful stimuli localizes to painful stimuli x obeys commands total vs hr bp rr ra gen no acute distress complains of ha appears well heent pupils 5mm bilaterally eoms intact extremities warm and well perfused neuro mental status awake and alert cooperative normal affect orientation oriented to person place and date language speech fluent with good comprehension and repetition naming intact no dysarthria or paraphasic errors cranial nerves i not tested ii perrl 5mm visual fields are full to confrontation iii iv vi eomi bilaterally without nystagmus v vii facial strength and sensation intact and symmetric viii hearing intact xi sternocleidomastoid and trapezius normal bilaterally xii tongue midline without fasciculations motor normal bulk and tone bilaterally no abnormal movements tremors strength full power throughout no pronator drift sensation intact to light touch on discharge temp po bp l sitting hr rr o2 sat o2 delivery ra exam sitting in bed comfortable anxious and awaiting plan for discharge opens eyes x spontaneous to voice to noxious orientation x person x place x time follows commands simple x complex none pupils perrl 3mm to 2mm eom x full restricted face symmetric x no very slight left ptosis left facial activates symmetrically tongue midline x yes no pronator drift yes x no speech fluent x yes no comprehension intact x yes no motor no drift moves all extremities symmetric full strength throughout sensation grossly intact to light touch wound clean dry intact sutures removed today wound well approximated no signs of infection pertinent results please see omr for pertinent lab results and imaging brief hospital course subarachnoid hemorrhage on ms was admitted to the neuro icu with diffuse left sided sah she was started on keppra nimodipine and nicardipine diagnostic angiogram was initially negative for aneurysm she was admitted to the stroke neurology service to evaluate for cns vasculitis as etiology for hemorrhage mri brain w w contrast was obtained revealing multiple lobar distributed microhemorrhages suspicious of caa and an acute left thalamic stroke she was transferred to on lp was performed and was revealing for elevated op and elevated rbc s as well as hsv for which she was started of acyclovir for a total course of days repeat cta on revealed a 2mm aneurysm superior to left carotid terminus she was transferred back to neuro icu and arterial line was placed for close blood pressure control on she was taken to the or for elective clipping of left ica aneurysm postoperatively she was noted to have new expressive aphasia revealed infarct in the left internal capsule and thalamus which were present on prior imaging speech improved during her icu stay her mental status continued to improve she continued her nimodipine for days post sah continue to express concerns for cognition and home safety and recommended home with 24h supervision social work was consulted on the patient was transferred to the floor she completed her dexamethasone taper left craniotomy site sutures were removed on prior to discharge dispo patient had an argument with her healthcare proxy because she felt the hcproxy was sabotaging her discharge to go home independently she discontinued communication with the health care proxy and named her daughter hcp the patient s son and daughter are unable to provide 24h supervision upon discharge home she has sisters in one is old and unable to provide care while the other she has a turbulent relationship with per her daughter psychiatry was consulted for capacity evaluation and a team meeting was held to discuss a safe dispo plan and social work are in agreement that patient would be safe to go home with services at home and frequent checks from family and friends patient s daughter to tentatively return to the on for work business and will stay with her mother re evaluated patient on and deemed the patient to have capacity to make her own medical decisions the patient has agreed to discharge home with maximum services including and social work has assisted the patient to set up elder services upon return home the patient reports that her friend has agreed that the patient can stay with her tonight after discharge patient s daughter has been in touch with case management and is aware of this current plan for discharge home with maximum services hyponatremia on admission the patient was hyponatremic to she was bolused with normal saline and sodium normalized she was again hyponatremic to on and started on hypertonic saline this was eventually weaned and she remained stable on salt tabs 1g po tid plan to wean salt tabs to off after discharge and the patient will follow up with pcp upon discharge hyperkalemia the patient was noted to have intermittent hyperkalemia with k up to on morning of discharge subsequent lab draw in was the patient was encouraged to increase po intake and she will follow up with her pcp as an outpatient for further monitoring and management fever the patient was febrile on and pancultured cxr was concerning for infection vs underlying airway disease hsv pcr was positive and she was started on acyclovir on with end date of further work up revealed uti and she was started on macrobid which was completed on aha asa core measures for ich dysphagia screening before any po intake x yes no dvt prophylaxis administered x yes no smoking cessation counseling given yes x no reason x non smoker unable to participate stroke education given in written form x yes no assessment for rehabilitation and or rehab services considered yes x no at baseline functional status stroke measures was performed within 6hrs of arrival x yes no was a procoagulant reversal agent given yes x no reason stable small sah was nimodipine given x yes no reason medications on admission aspirin 81mg discharge medications acetaminophen mg po q6h prn pain mild fever reason for prn duplicate override patient is npo or unable to tolerate po nimodipine mg po q4h rx nimodipine mg two capsule s by mouth every four hours disp capsule refills sodium chloride gm po bid rx sodium chloride gram tablet s by mouth bid x2 days then qd x2 days disp tablet refills discharge disposition home with service facility discharge diagnosis subarachnoid hemorrhage left ica bifurcation aneurysm hsv discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear you were hospitalized due to symptoms of headache resulting from a subarachnoid hemorrhage this is a condition caused by a leakage of blood within the brain while you were here in the hospital you had an angiogram to look for an aneurysm fortunately this showed no evidence of hemorrhage you also had a lumbar puncture this showed hsv and you were started on acyclovir for a total course of days please take your 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 aneurysmal subarachnoid hemorrhage please do not take any blood thinning medication aspirin plavix coumadin until cleared by the neurosurgeon you have been discharged on a medication called nimodipine this medication is used to help prevent cerebral vasospasm narrowing of blood vessels in the brain what you experience mild to moderate headaches that last several days to a few weeks difficulty with short term memory fatigue is very normal when to call your doctor at for severe pain swelling redness or drainage from the incision site or puncture site fever greater than degrees fahrenheit constipation blood in your stool or urine nausea and or vomiting extreme sleepiness and not being able to stay awake severe headaches not relieved by pain relievers seizures any new problems with your vision or ability to speak weakness or changes in sensation in your face arms or leg call and go to the nearest emergency room if you experience any of the following sudden numbness or weakness in the face arm or leg sudden confusion or trouble speaking or understanding sudden trouble walking dizziness or loss of balance or coordination sudden severe headaches with no known reason while you were hospitalized an additional cta was performed revealing a new 2mm left ica bifurcation aneurysm for which you underwent a left craniotomy for clipping treatment of your aneurysm discharge instructions for elective aneurysm clipping call your neurosurgeon s office and speak to the nurse practitioner if you experience any neurological issues such as change in vision speech or movement swelling drainage or redness of your incision any problems with medications such as nausea vomiting or lethargy fever greater than degrees fahrenheit headaches not relieved with prescribed medications activity start to resume all activities as you tolerate but start slowly and increase at your own pace do not operate any motorized vehicle for at least days after your surgery your nurse practitioner can give you more detail at the time of your suture removal your sutures will be removed prior to discharge incision care keep your wound clean and dry do not use shampoo until your sutures are removed when you are allowed to shampoo your hair let the shampoo run off the incision line gently pad the incision with a towel to dry do not rub scrub scratch or pick at any scabs on the incision line you need your sutures removed to days after surgery post operative experiences physical jaw pain on the same side as your surgery this goes away after about a month you may experience constipation constipation can be prevented by o drinking plenty of fluids o increasing fiber in your diet by eating vegetables prunes fiber rich breads and cereals or fiber supplements o exercising o using over the counter bowel stimulants or laxatives as needed stopping usage if you experience loose bowel movements or diarrhea fatigue which will slowly resolve over time numbness or tingling in the area of the incision this can take weeks or months to fully resolve muffled hearing in the ear near the incision area low back pain or shooting pain down the leg which can resolve with increased activity post operative experiences emotional you may experience depression symptoms of depression can include o feeling down or sad o irritability frustration and confusion o distractibility o lower self esteem relationship challenges o insomnia o loneliness if you experience these symptoms you can contact your primary care provider who can make a referral to a psychologist or psychiatrist you can also seek out a local brain aneurysm support group in your area through the brain aneurysm foundation o more information can be found at 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 chronic cholecystitis major surgical or invasive procedure laparoscopic cholecystectomy history of present illness the patient is a with ruq pain for the past hours that woke him from sleep he had similar pain last night as well after eating a cheeseburger which improved on its own today the pain is constant and not improving he endorses nausea but no vomiting no fevers at home his bowels have been overall normal but he thinks a little more constipated than usual due to decreased water intake no bloody stools he tried taking prune juice when his pain started this morning which made his pain worse he did have one prior episode of abdominal pain similar to this when he was seen in the ed last year and was sent home with a bowel regimen past medical history non contributory social history family history non contributory physical exam prior to discharge vs ra gen pleasant with nad heent no scleral icterus cv rrr no m r g pulm ctab abd laparoscopic incisions open to air and c d i extr warm no c c e pertinent results 15am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 15am blood glucose urean creat na k cl hco3 angap 15am blood alt ast alkphos totbili gallbladder us impression cholelithiasis without evidence of gallbladder wall thickening or gallbladder distention negative sonographic signs of note there is a cm stone in the gallbladder neck brief hospital course the patient was admitted to the acute surgical service on for evaluation and treatment of abdominal pain admission abdominal ultra sound revealed gallstone disease the patient underwent laparoscopic cholecystectomy which went well without complication reader referred to the operative note for details after a brief uneventful stay in the pacu the patient arrived on the floor tolerating clear liquid on iv fluids and oxycodone for pain control the patient was hemodynamically stable pain was well controlled diet was progressively advanced as tolerated to a regular diet with good tolerability the patient voided without problem during this hospitalization the patient ambulated early and frequently was adherent with respiratory toilet and incentive spirrometry and actively participated in the plan of care the patient received subcutaneous heparin and venodyne boots were used during this stay at the time of discharge on pod the patient was doing well afebrile with stable vital signs the patient was tolerating a regular diet ambulating voiding without assistance and pain was well controlled the patient was discharged home without services the patient received discharge teaching and follow up instructions with understanding verbalized and agreement with the discharge plan medications on admission none discharge medications acetaminophen mg po q6h prn pain mild reason for prn duplicate override alternating agents for similar severity docusate sodium mg po bid rx docusate sodium mg capsule s by mouth twice a day disp capsule 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 every four hours disp tablet refills discharge disposition home discharge diagnosis chronic cholecystitis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted to the surgery service at with acute cholecystitis you underwent cholecystectomy you have done well in the post operative period and are now safe to return home to complete your recovery with the following instructions please call acute care surgery at if you have any questions or concerns please resume all regular home medications unless specifically advised not to take a particular medication also please take any new medications as prescribed please get plenty of rest continue to ambulate several times per day and drink adequate amounts of fluids avoid lifting weights greater than lbs until you follow up with your surgeon who will instruct you further regarding activity restrictions avoid driving or operating heavy machinery while taking pain medications please follow up with your surgeon and primary care provider pcp as advised incision care please call your doctor or nurse practitioner if you have increased pain swelling redness or drainage from the incision site avoid swimming and baths until your follow up appointment you may shower and wash surgical incisions with a mild soap and warm water gently pat the area dry followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies penicillins attending chief complaint sore throat major surgical or invasive procedure egd history of present illness with pmhx of htn presents with chest pain and sore throat per patient she notes that 2d pta she developed a foreign body sensation in her throat she notes that since development it is always there and is associated with dysphagia and odynophagia she denies issues with secretions vomiting nausea hematemesis abdominal pain diarrhea melena brbpr she denies foreign body ingestion she notes that she went to an outpatient gi appointment where she was expecting definitive treatment and elected to present to the ed as no endoscopy was planned for that day it was recommended that she undergo gi consultation for possible esophageal spasm she denies a history of progressive dysphagia to solids or liquids in the ed initial vitals ra labs were significant for normal cbc chem7 bun cr near atrius baseline negative trop x imaging showed cxr poor inspiratory effort cardiomegaly cephalization of vasculature right hilar fullness no effusions or focal infiltrates my read in the ed she received no medications exam remarkable for ttp over sternum past medical history htn ifgt hld obesity depression positive ppd social history family history daughter required esophageal dilation for stricture in mid physical exam admission vs ra gen alert lying in bed no acute distress heent moist mm anicteric sclerae no conjunctival pallor neck supple without lad pulm ctab without wheeze or rhonchi cor rrr s1 s2 no m r g abd soft non tender non distended extrem warm well perfused no edema discharge vitals ra gen wdwn female in nad heent anicteric mom symmetric palatal elevation no retropharyngeal edema exudate neck supple jvp not elevated no lad masses fluctuance lungs clear to auscultation bilaterally no wheezes rales ronchi cv rrr normal s1s2 no m r g abd obese soft nt nd nabs gu no foley ext wwp pulses no cyanosis or edema neuro a ox3 face symmetric mae skin warm and dry pertinent results admission labs 00pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 00pm neuts monos eos basos im absneut abslymp absmono abseos absbaso 00pm glucose urea n creat sodium potassium chloride total co2 anion gap 00pm ctropnt pertinent studies 08am blood ck mb ctropnt 30pm urine color straw appear clear sp 30pm urine blood neg nitrite neg protein neg glucose neg ketone neg bilirub neg urobiln neg ph leuks neg imaging chest pa lat study date of no radiopaque foreign body seen projecting over the course of the esophagus egd impression erythema friability and congestion with exudates in the lower third of the esophagus and middle third of the esophagus compatible with esophagitis biopsy otherwise normal egd to third part of the duodenum recommendations will contact you with biopsy results start po omeprazole mg q12h for now diet as tolerated discharge labs 15am blood glucose urean creat na k cl hco3 angap 15am blood calcium phos mg female with history of htn hld ifgt and obesity who presented with days of odynophagia to solids and liquids without evidence of airway compromise autoimmune symptoms anemia or abscess she underwent upper endoscopy which was notable for esophagitis without evidence of bleeding mucosal biopsies pending at time of discharge patient responded to iv ppi bid and continued to improve on oral ppi bid she was tolerating regular diet and was discharged on omeprazole 40mg bid with pcp follow up odynophagia presented with days of throat pain subjective throat swelling and inability to swallow initially there was concern for cardiac etiology given sub sternal nature of the pain but ekg unremarkable for ischemia and troponin was negative x no foreign body identified on cxr no pneumomediastinum or subcutaneous emphysema treated with diltiazem for concern for diffuse esophageal spasm but patient did not respond to this therapy patient underwent egd that showed erythema and exudates in mid and distal esophagus which likely represents esophagitis from reflux she was started on iv ppi bid with good response to anti reflux therapy she was tolerating regular diet and was discharged on omeprazole 40mg bid with pcp follow up biopsies pending at time of discharge chronic issues htn home medications initially held given normotension and poor oral intake bp rose after endoscopy and with resumption of oral nutrition restarted home lisinopril 10mg qd triamterene hctz qd hld home statin initially held given interaction between pravastatin and diltiazem for possible esophageal spasm diltiazem was discontinued and restarted home simvastatin 20mg qd allergic rhinitis stable continued home fluticasone and held home cetirizine pseudoephedrine code full confirmed communication son transitional issues started on bid omeprazole 40mg mucosal biopsies pending at discharge medications on admission the preadmission medication list is accurate and complete lisinopril mg po daily simvastatin mg po qpm triamterene hctz cap po daily fluticasone propionate nasal spry nu daily cetirizine pseudoephedrine mg oral q12h ibuprofen mg po q8h prn pain moderate discharge medications omeprazole mg po q12h rx omeprazole mg capsule s by mouth every twelve hours disp capsule refills cetirizine pseudoephedrine mg oral q12h fluticasone propionate nasal spry nu daily ibuprofen mg po q8h prn pain moderate lisinopril mg po daily simvastatin mg po qpm triamterene hctz cap po daily discharge disposition home discharge diagnosis primary reflux esophagitis 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 on with painful swallowing you had an endoscopy that showed damage from acid reflux you were started on a twice daily acid blocking medication and your symptoms improved you were able to eat and drink prior to leaving the hospital please continue to take the acid blocker omeprazole twice a day follow up with your primary care physician if you develop throat swelling drooling voice changes shortness of breath or have bloody vomiting please contact your physician immediately or return to the hospital we wish you the best in health sincerely your team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies sulfa sulfonamide antibiotics attending chief complaint nausea vomiting major surgical or invasive procedure none history of present illness with a history of t1d on humalog insulin pump followed by dr at htn hypothyroid and recent stroke weeks ago without residual deficits who is admitted for dka he reports that his blood sugar has been under good control today low 200s until this morning when he noted it to be prior to breakfast he then went out to eat and when he returned noted his glucose to be in the 500s he set his pump to deliver additional insulin boluses and reports that he received approximately units between 3pm and 9pm when he presented to the he typically receives a basal infusion plus boluses of for meals he reports episodes of nbnb vomiting no fevers chills abdominal pain diarrhea dysuria or cough no known sick contacts he was initially diagnosed with t1d in and received an insulin pump years ago his bg was initially very difficult to control and he reports three prior episodes of dka last being in at which time he was thought to have a pump malfunction and it was replaced at he was found to have a bg in the 500s bicarb and anion gap c w dka with wbc of cxr concerning for a possible pneumonia and he was initiated on vanc zosyn he was started on an insulin drip given l of fluids and transferred here since no icu beds available at the patient felt well on arrival to our denied any pain and breathing comfortably clear lungs and normal heart sounds soft and non tender abdomen mild tachycardia 90s 100s with stable bps 130s 50s sao2 ra he was continued on an insulin drip l ns administered additional l with k running at per hour antibiotics continued with vanc and zosyn labs wbc bicarb glucose anion gap k ros positives as per hpi otherwise negative past medical history t1dm hypothyroid hypertension prior cva social history family history not obtained physical exam admission physical exam vs hr bp o2 ra bg gen well appearing heent no jvd cv rrr resp ctab gi soft non tender non distended msk no abnormalities skin wwp neuro mentating appropriately neurologic exam grossly intact discharge physical exam hr data last updated temp tm bp hr rr o2 sat o2 delivery ra gen alert nad appears comfortable cv rrr no m r g pulm breathing comfortably clear to auscultation bilaterally no wheezes ronchi or crackles neuro aaox3 grossly intact moving all extremities spontaneously and with purpose pertinent results admission laboratory studies 20am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 01am blood ptt 20am blood glucose urean creat na k cl hco3 angap 20am blood phos mg 25am blood beta oh 26am blood glucose lactate na k cl calhco3 25am blood po2 pco2 ph caltco2 base xs discharge and pertinent laboratory studies reports and imaging studies impression low lung volumes no good evidence for cardiopulmonary abnormality although no acute or other chest wall lesion is seen conventional chest radiographs are not sufficient for detection or characterization of most such abnormalities if the demonstration of trauma or other osseous soft tissue abnormality involving the chest wall is clinically warranted the location of any referable focal findings should be described in the imaging request clearly marked and imaged with either bone detail radiographs or chest ct scanning microbiology blood culture blood culture discharge labs 43am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 43am blood plt 43am blood glucose urean creat na k cl hco3 angap 43am blood calcium phos mg brief hospital course mr is a year old man with a history of t1d on humalog insulin pump followed by dr at htn hypothyroid and recent stroke weeks ago without residual deficits who is admitted for dka diabetic ketoacidosis mr presented in dka with anion gap of serum glucose of elevated beta hydroxybuterate and a metabolic acidosis he was initiated on an insulin infusion normal saline boluses and potassium and phosphate repletion his gap rapidly closed and his beta hydroxy buterate trended to zero his acidosis also rapidly resolved his insulin infusion was eventually weaned down per protocol and when it reached 4u hour we initiated insulin subcutaneously with a initial basal dose of 28u glargine standing humalog of 3u per meal and a sliding scale he was able to eat at this time and he was then transferred to the floor the etiology of his dka was not immediately clear he reports multiple prior episodes cxr did not reveal pneumonia and a ua at an osh did not show evidence of infection his leukocytosis was thought to be reactive there was concern that his insulin pump may have malfunctioned though there was no clear evidence this was the case endocrinology was consulted floor course dka now resolved type i dm patient was continued on sc insulin at the time of transfer to the floor due to some issue with his insulin order the patient did not receive his qhs glargine on the evening of subsequently had high bg readings the next am w sugars in the 400s he received 28u of lantus and ivf w improvement in his sugars he had his insulin adjusted by and be discharged with a regimen of he will follow up with his endocrinologist dr hx recent cva mild aphasia patient and his wife were concerned about him exhibiting word finding difficulties cardinal symptom noted during stroke a couple weeks ago and some fine motor difficulties he was unable to write in his usual cursive and instead tried to write in print unable to draw his wife a picture and per her is usually a great artist at the time of his admission to the micu this was thought to be most likely recrudescence in the setting of his dka as it improved w treatment of that condition patient notably with a recent cva weeks ago during which neuro noted reported l subcortical location and distribution of the stroke is most consistent with a small vessel occlusive mechanism carotid u s noting bilateral carotid bulb and proximal ica soft atherosclerotic plaque left right carotid disease thought to be possibly the culprit though no residual disease which would be amenable to surgical intervention tte fairly unremarkable and w o e o intracardiac thrombi sent home w holter monitor no results communicated to patient yet he reports history of intermittent fast heart rate but is not sure if it is a fib and no documented history of this per notes appears to be some unspecified svt w avnrt noted on tele on the am of he was monitored for the rest of the admission and with no concern for new deficits which might suggest a cva he will be referred to neuro at the time of discharge svt likely avnrt patient w self limited episodes of svt which appeared to be avnrt on the am of he was hemodynamically stable and asymptomatic he reports having palpitations in the past and having fast heart rates followed by dr notably not on any nodal blockade as an outpatient he was started on a low dose of metoprolol but was limited by bradycardia so he was not discharged on this hypertension sbp in the 200s overnight on but reassuringly asymptomatic he continued to have elevated bps during this admission and so had his antihypertensive regimen titrated he was on a regimen including an increased dose of lisinopril at the time of discharge leukocytosis admitted w a wbc of 20k thought to be reactive in the setting of dka wbc downtrended over the course of the admission and the patient had no localizing signs symptoms of infection chronic issues hyperlipidemia continued home atorvastatin hypothyroid continued home levothyroxine transitional issues patient discharged on basal bolus insulin regimen he should follow up with his endocrinologist dr discharged on lisinopril for hypertension follow up bp for titration of his antihypertensives patient referred to neuro for follow up after his recent cva medications on admission the preadmission medication list may be inaccurate and requires futher investigation atorvastatin mg po qpm clopidogrel mg po daily lisinopril mg po daily tadalafil mg oral daily fluticasone propionate nasal spry nu frequency is unknown levothyroxine sodium mcg po daily aspirin mg po daily discharge medications glargine units bedtime humalog units breakfast humalog units lunch humalog units dinner insulin sc sliding scale using hum insulin rx insulin glargine basaglar kwikpen u insulin unit ml ml as dir units before bed disp syringe refills rx insulin lispro humalog kwikpen insulin unit ml as dir up to units qid per sliding scale units before lnch units qid per sliding scale units before dinr units qid per sliding scale disp syringe refills fluticasone propionate nasal spry nu daily nasal congestion lisinopril mg po daily rx lisinopril mg tablet s by mouth once a day disp tablet refills aspirin mg po daily atorvastatin mg po qpm clopidogrel mg po daily levothyroxine sodium mcg po daily tadalafil mg oral daily discharge disposition home discharge diagnosis dka svt hypertensive urgency discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions discharge instructions dear mr it was a pleasure caring for you at why was i in the hospital you were confused and feeling unwell at home and were found to be in a dangerous condition called diabetic ketoacidosis what happened to me in the hospital you were admitted to the icu where you were given insulin fluid and electrolytes your condition improved quite quickly you were evaluated by the doctors from your insulin regimen was adjusted and you will go out on injectable insulin instead of your insulin pump you had elevated blood pressures and had your blood pressure medications increased what should i do after i leave the hospital please take your medications and go to your follow up appointments as described in this discharge summary if you experience any of the danger signs listed below please call your primary care doctor or go to the emergency department immediately we wish you the best sincerely your team followup instructions

name unit no admission date discharge date date of birth sex f service surgery allergies morphine attending chief complaint fall with r orbital fracture major surgical or invasive procedure none history of present illness y o female presents with right orbital fracture on ct from osh and right knee pain after a fall this morning the fall occurred at 2am while she was walking downstairs in her home she fell forward on the last step and recalls hitting her knee and the right side of her face on the floor the fall was not witnessed she lives with her daughter s family and they found her down immediately after the incident she remembers the event and there are no reports of loc by family members she was taken to an osh where ct imaging showed evidence of a right orbital fracture was referred to to assess need for surgical intervention she has no reported falls in the past she has right knee pain some pain on her right flank and a headache she denies nausea vomiting past medical history past medical history diabetes htn arthritis past surgical history left knee surgery cholecystectomy cataract surgery social history family history non contributory physical exam discharge physical exam gen aaox3 nad lying comfortably in bed heent mmm no scleral icterus resp nl effort ctabl no wheezes rales rhonchi cv rrr nl s1 s2 no s3 s4 no murmurs rubs gallops abd bs soft nd appropriately tender to palpation ext wwp no edema dp physical examination upon discharge pertinent results 34am glucose urea n creat sodium potassium chloride total co2 anion gap 34am estgfr using this 34am wbc rbc hgb hct mcv mch mchc rdw rdwsd 34am neuts lymphs monos eos basos im absneut abslymp absmono abseos absbaso 34am plt count 34am ptt 28pm urine hours random 28pm urine hours random 28pm urine uhold hold 28pm urine gr hold hold 28pm urine color straw appear clear sp 28pm urine blood neg nitrite neg protein glucose tr ketone neg bilirubin neg urobilngn neg ph leuk neg 28pm urine rbc wbc bacteria none yeast none epi imaging head ct at osh showed right orbital fracture ct of high lower extremity w o contrast moderate to large high density joint effusion suggests the possibility of hemarthrosis no fracture identified moderate to severe tricompartmental degenerative changes ct torso no traumatic injuries assessment plan y o female with right orbital fracture and right knee pain swelling s p fall w o loc while walking down the stairs this morning no concern for neurological injury based on history and physical exam and thus no need for operative management right knee is tender with mild swelling but there is no evidence of fracture on imaging plan to discharge home with c brief hospital course ms is a old woman who had fallen down stairs landing on her right side she was transferred to on from for further management of a right orbital fracture and r knee swelling and pain ophthalmology was consulted and recommended sinus precautions for week including no nose blowing no drinking out of straw no smoking they also recommended follow up with her regular ophthalmologist in week for dilated fundus exam she should also seek ophthalmic evaluation sooner as outpatient if she experiences new onset flashes floaters diplopia decrease in vision or other significant ophthalmic concerns a right lower extremity ct was obtained on which showed knee joint effusion with possible hemarthrosis no fracture and severe tricompartmental degenerative changes orthopedic surgery was consulted and recommended ace wrap to right knee for support weight bearing as tolerated follow up with pcp and follow up in clinic as needed on the patient was reported to have a decreased urine output and was given additional intravenous fluids she had kidney studies done and was reported to be in her creatinine peaked at her kidney function tests were measured and at the time of discharge her creatinine was with a bun of the patient s vital signs remained stable and she was afebrile she was tolerating a regular diet she did have some bacteria in her urine but was asymptomatic in preparation for discharge she was evaluated by physical therapy who made recommendations for discharge to a rehabilitation facility where the patient could regain her strength and mobility the patient was discharged on hd in stable condition appointments for follow up were made with the plastic surgery service and with her primary care provider medications on admission atenolol mg po daily hypertension glipizide mg po bid metformin glucophage mg po bid nifedipine cr mg po daily hypertension discharge medications acetaminophen mg po q6h prn pain mild heparin unit sc bid d c when patient ambulatory simethicone mg po qid prn bloating tramadol mg po q6h prn pain atenolol mg po daily hypertension glipizide mg po bid metformin glucophage mg po bid nifedipine cr mg po daily hypertension omeprazole mg po daily discharge disposition extended care facility discharge diagnosis right orbital floor fracture right knee 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 ms you were admitted to for evaluation and treatment of your injuries after a fall please follow the instructions below to continue your recovery apply ice ice helps decrease swelling and pain ice may also help prevent tissue damage use an ice pack or put crushed ice in a plastic bag cover it with a towel and place it on your face for to minutes every hour as directed keep your head elevated keep you head above the level of your heart as often as you can this will help decrease swelling and pain prop your head on pillows or blankets to keep it elevated comfortably avoid putting pressure on your face do not sleep on the injured side of your face pressure on the area of your injury may cause further damage sneeze with your mouth open to decrease pressure on your broken facial bones too much pressure from a sneeze may cause your broken bones to move and cause more damage try not to blow your nose because it may cause more damage if you have a fracture near your eye the pressure from blowing your nose may pinch the nerve of your eye and cause permanent damage contact your primary healthcare provider you have double vision or you suddenly have problems with your eyesight you have questions or concerns about your condition or care return to the emergency department if you have clear or pinkish fluid draining from your nose or mouth you have numbness in your face you have worsening pain in your eye or face you suddenly have trouble chewing or swallowing you suddenly feel lightheaded and short of breath you have chest pain when you take a deep breath or cough you may cough up blood your arm or leg feels warmer more tender or more painful it may look swollen and red regarding your knee injury rest your knee so it can heal limit activities that increase your pain ice can help reduce swelling wrap ice in a towel and put it on your knee for as long and as often as directed compression with a brace or bandage can help reduce swelling use a brace or bandage only as directed elevation helps decrease pain and swelling elevate your knee while you are sitting or lying down prop your leg on pillows to keep your knee above the level of your heart 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 abdominal pain major surgical or invasive procedure laparoscopy appendectomy history of present illness patient presents with hours of acute abdominal pain symptoms began suddenly upon waking this am pain was initially at periumbillical area but now radiated to his rlq reports one episode of emesis and anorexia denies fever chills diarrhea and urinary symptoms has not tried analgesics for symptoms upon evaluation no acute distress vss abdomen soft non distended he has localized tenderness with rebound at rlq otherwise his abdomen is soft pain is reproducible with rle extension also has psoas sign no rovsing work up notable for leukocytosis to with left shift imaging demonstrating inflamed retrocecal appendix without signs of perforation past medical history none social history family history non contributory physical exam admission physical exam vitals ra gen a o nad heent no scleral icterus mucus membranes moist cv rrr no m g r pulm clear to auscultation b l no w r r abd tenderness with localized rebound at rlq otherwise is soft nondistended nontender psoas sign ext no edema warm and well perfused discharge physical exam vs po ra gen awake alert pleasant and interactive cv rrr pulm clear bilaterally abd soft mildly tender incisionally as anticipated mildly distended ext warm and dry pulses neuro a ox3 follows commands and moves all extremities equal and strong speech is clear and fluent pertinent results 37pm blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 37pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 37pm blood glucose urean creat na k cl hco3 angap 03am blood calcium phos mg bd pelvis with contrast clip impression acute appendicitis without evidence of gross perforation brief hospital course mr is a yo m who was admitted to the acute care surgery service on with abdominal pain and found to have acute appendicitis on ct scan informed consent was obtained and the patient underwent laparoscopic appendectomy on please see operative report for details after a brief uneventful stay in the pacu the patient arrived on the floor tolerating clear liquid diet on iv fluids and iv dilaudid for pain control the patient was hemodynamically stable when tolerating a diet the patient was converted to oral pain medication with continued good effect diet was progressively advanced as tolerated to a regular diet with good tolerability the patient voided without problem during this hospitalization the patient ambulated early and frequently was adherent with respiratory toilet and incentive spirometry and actively participated in the plan of care the patient received subcutaneous heparin and venodyne boots were used during this stay at the time of discharge the patient was doing well afebrile with stable vital signs the patient was tolerating a regular diet ambulating voiding without assistance and pain was well controlled the patient was discharged home without services the patient received discharge teaching and follow up instructions with understanding verbalized and agreement with the discharge plan medications on admission none discharge medications acetaminophen mg po q6h rx acetaminophen mg tablet s by mouth every six hours disp tablet refills docusate sodium mg po bid oxycodone immediate release mg po q4h prn pain moderate rx oxycodone mg tablet s by mouth every four hours disp tablet refills simethicone mg po qid prn gas pain discharge disposition home discharge diagnosis appendicitis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr you were admitted to the hospital with abdominal pain and found to have an infection in your appendix you were taken to the operating room and had your appendix removed laparoscopically you tolerated the procedure well and are now being discharged home to continue your recovery with the following instructions please follow up in the acute care surgery clinic at the appointment listed below activity o do not drive until you have stopped taking pain medicine and feel you could respond in an emergency o you may climb stairs o you may go outside but avoid traveling long distances until you see your surgeon at your next visit o don t lift more than lbs for weeks this is about the weight of a briefcase or a bag of groceries this applies to lifting children but they may sit on your lap o you may start some light exercise when you feel comfortable o you will need to stay out of bathtubs or swimming pools for a time while your incision is healing ask your doctor when you can resume tub baths or swimming how you may feel o you may feel weak or washed out for a couple of weeks you might want to nap often simple tasks may exhaust you o you may have a sore throat because of a tube that was in your throat during surgery o you might have trouble concentrating or difficulty sleeping you might feel somewhat depressed o you could have a poor appetite for a while food may seem unappealing o all of these feelings and reactions are normal and should go away in a short time if they do not tell your surgeon your incision o tomorrow you may shower and remove the gauzes over your incisions under these dressing you have small plastic bandages called steri strips do not remove steri strips for weeks these are the thin paper strips that might be on your incision but if they fall off before that that s okay o your incisions may be slightly red around the stitches this is normal o you may gently wash away dried material around your incision o avoid direct sun exposure to the incision area o do not use any ointments on the incision unless you were told otherwise o you may see a small amount of clear or light red fluid staining your dressing or clothes if the staining is severe please call your surgeon o you may shower as noted above ask your doctor when you may resume tub baths or swimming your bowels o constipation is a common side effect of narcotic pain medications if needed you may take a stool softener such as colace one capsule or gentle laxative such as milk of magnesia tbs twice a day you can get both of these medicines without a prescription o if you go hours without a bowel movement or have pain moving the bowels call your surgeon pain management o it is normal to feel some discomfort pain following abdominal surgery this pain is often described as soreness o your pain should get better day by day if you find the pain is getting worse instead of better please contact your surgeon o you will receive a prescription for pain medicine to take by mouth it is important to take this medicine as directed o do not take it more frequently than prescribed do not take more medicine at one time than prescribed o your pain medicine will work better if you take it before your pain gets too severe o talk with your surgeon about how long you will need to take prescription pain medicine please don t take any other pain medicine including non prescription pain medicine unless your surgeon has said its okay o if you are experiencing no pain it is okay to skip a dose of pain medicine o remember to use your cough pillow for splinting when you cough or when you are doing your deep breathing exercises if you experience any of the following please contact your surgeon sharp pain or any severe pain that lasts several hours pain that is getting worse over time pain accompanied by fever of more than a drastic change in nature or quality of your pain medications take all the medicines you were on before the operation just as you did before unless you have been told differently if you have any questions about what medicine to take or not to take please call your surgeon followup instructions

name unit no admission date discharge date date of birth sex f service orthopaedics allergies sulfa drugs attending chief complaint right knee pain major surgical or invasive procedure right total knee arthroplasty history of present illness year old female with right knee pain presents for joint replacement past medical history seizures as an infant depression anxiety hld obesity social history family history nc 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 50pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 10am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30am 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 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 unremarkable otherwise pain was controlled with a combination of iv and oral pain medications the patient received lovenox for dvt prophylaxis starting on the morning of pod the foley was removed and the patient was voiding independently thereafter the surgical dressing was changed and the silverlon dressing was removed on pod the surgical incision was found to be clean and intact without erythema or abnormal drainage the patient was seen daily by physical therapy labs were checked throughout the hospital course and repleted accordingly at the time of discharge the patient was tolerating a regular diet and feeling well the patient was afebrile with stable vital signs the patient s hematocrit was acceptable and pain was adequately controlled on an oral regimen the operative extremity was neurovascularly intact and the wound was benign the patient s weight bearing status is weight bearing as tolerated on the operative extremity please use walker or crutches at all times for weeks ms is discharged to rehab in stable condition medications on admission the preadmission medication list is accurate and complete acetaminophen w codeine tab po bid prn pain moderate bupropion xl once daily mg po daily clonazepam mg po tid duloxetine mg po daily hydroxychloroquine sulfate mg po daily omeprazole mg po daily prn acid reflux pravastatin mg po qpm prednisone mg po daily acetaminophen mg po q8h prn pain mild discharge medications docusate sodium mg po bid enoxaparin sodium mg sc q12h start first dose first routine administration time oxycodone immediate release mg po q4h prn pain senna mg po bid acetaminophen mg po q8h bupropion xl once daily mg po daily clonazepam mg po tid duloxetine mg po daily omeprazole mg po daily prn acid reflux pravastatin mg po qpm held hydroxychloroquine sulfate mg po daily this medication was held do not restart hydroxychloroquine sulfate until four weeks postop held prednisone mg po daily this medication was held do not restart prednisone until four weeks postop discharge disposition extended care facility discharge diagnosis osteoarthritis right knee discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane expected length of stay in rehab less than days discharge instructions please return to the emergency department or notify your physician if you experience any of the following severe pain not relieved by medication increased swelling decreased sensation difficulty with movement fevers greater than shaking chills increasing redness or drainage from the incision site chest pain shortness of breath or any other concerns please follow up with your primary physician regarding this admission and any new medications and refills resume your home medications unless otherwise instructed you have been given medications for pain control please do not drive operate heavy machinery or drink alcohol while taking these medications as your pain decreases take fewer tablets and increase the time between doses this medication can cause constipation so you should drink plenty of water daily and take a stool softener such as colace as needed to prevent this side effect call your surgeons office days before you are out of medication so that it can be refilled these medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house please allow an extra days if you would like your medication mailed to your home you may not drive a car until cleared to do so by your surgeon please call your surgeon s office to schedule or confirm your follow up appointment swelling ice the operative joint minutes at a time especially after activity or physical therapy do not place ice directly on the skin you may wrap the knee with an ace bandage for added compression please do not take any non steroidal anti inflammatory medications nsaids such as celebrex ibuprofen advil aleve motrin naproxen etc anticoagulation please continue your lovenox for four weeks to help prevent deep vein thrombosis blood clots if you were taking aspirin prior to your surgery it is ok to continue at your previous dose while taking anticoagulation medication stockings x weeks wound care please keep your incision clean and dry it is okay to shower five days after surgery but no tub baths swimming or submerging your incision until after your four week checkup please place a dry sterile dressing on the wound each day if there is drainage otherwise leave it open to air check wound regularly for signs of infection such as redness or thick yellow drainage staples will be removed by at follow up appointment approximately two weeks after surgery once at home home dressing changes as instructed wound checks and staple removal at two weeks after surgery activity weight bearing as tolerated on the operative extremity two crutches or walker at all times for weeks mobilize rom as tolerated no strenuous exercise or heavy lifting until follow up appointment physical therapy weight bearing and range of motion as tolerated in right lower extremity on two crutches or a walker at all times treatments frequency dressing changes as needed wound checks physical therapy lovenox teaching staples to be removed at first clinic visit followup instructions

name unit no admission date discharge date date of birth sex f service orthopaedics allergies sulfa drugs shellfish derived attending chief complaint left knee osteoarthritis major surgical or invasive procedure left total knee arthroplasty on history of present illness mrs is who presents with left knee arthritis she presents for a left total knee arhtroplasty past medical history seizures as an infant depression anxiety hld obesity social history family history nc 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 18am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 28am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 20am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 18am blood plt 28am blood plt 20am blood plt 20am blood glucose urean creat na k cl hco3 angap 20am blood calcium phos mg 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 she was having increased pain on pod so she was provided with x1 dose of oxycodone she was having increased anxiety so she was provided night time dose of clonapin she typically takes klonapin 5mg tid plus 1mg qhs but patient reported that she takes more than this at home on pod she no longer showed signs of withdrawal acute post operative blood loss anemia hct pod patient is asymptomatic with normal vital signs please do not perform labs unless patient becomes symptomatic please call the orthopaedic surgery department prior to iniating work up or sending to the emergency department 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 surgical dressing was changed and the silverlon dressing was removed on pod the surgical incision was found to be clean and intact without erythema or abnormal drainage the patient was seen daily by physical therapy labs were checked throughout the hospital course and repleted accordingly at the time of discharge the patient was tolerating a regular diet and feeling well the patient was afebrile with stable vital signs the patient s hematocrit was acceptable and pain was adequately controlled on an oral regimen the operative extremity was neurovascularly intact and the wound was benign the patient s weight bearing status is weight bearing as tolerated on the operative extremity please use walker or crutches at all times for weeks ms is discharged to rehab in stable condition medications on admission albuterol inhaler puff ih q6h prn wheezing bupropion xl once daily mg po daily clonazepam mg po tid prn anxiety duloxetine mg po daily hydroxychloroquine sulfate mg po daily lisinopril mg po daily omeprazole mg po daily pravastatin mg po qpm discharge medications acetaminophen mg po q8h docusate sodium mg po bid enoxaparin sodium mg sc daily start first dose next routine administration time oxycodone immediate release mg po q4h prn pain moderate senna mg po bid clonazepam mg po qhs albuterol inhaler puff ih q6h prn wheezing bupropion xl once daily mg po daily clonazepam mg po tid prn anxiety duloxetine mg po daily hydroxychloroquine sulfate mg po daily lisinopril mg po daily omeprazole mg po daily pravastatin mg po qpm discharge disposition extended care facility discharge diagnosis left knee osteoarthritis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions please return to the emergency department or notify your physician if you experience any of the following severe pain not relieved by medication increased swelling decreased sensation difficulty with movement fevers greater than shaking chills increasing redness or drainage from the incision site chest pain shortness of breath or any other concerns please follow up with your primary physician regarding this admission and any new medications and refills resume your home medications unless otherwise instructed you have been given medications for pain control please do not drive operate heavy machinery or drink alcohol while taking these medications as your pain decreases take fewer tablets and increase the time between doses this medication can cause constipation so you should drink plenty of water daily and take a stool softener such as colace as needed to prevent this side effect call your surgeons office days before you are out of medication so that it can be refilled these medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house please allow an extra days if you would like your medication mailed to your home you may not drive a car until cleared to do so by your surgeon please call your surgeon s office to schedule or confirm your follow up appointment swelling ice the operative joint minutes at a time especially after activity or physical therapy do not place ice directly on the skin you may wrap the knee with an ace bandage for added compression please do not take any non steroidal anti inflammatory medications nsaids such as celebrex ibuprofen advil aleve motrin naproxen etc until cleared by your physician 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 please hold this medication until you have completed your one month course of anticoagulation medication or unless cleared by your physician wound care please keep your incision clean and dry it is okay to shower five days after surgery but no tub baths swimming or submerging your incision until after your four week checkup please place a dry sterile dressing on the wound each day if there is drainage otherwise leave it open to air check wound regularly for signs of infection such as redness or thick yellow drainage staples will be removed by at follow up appointment approximately two weeks after surgery once at home home dressing changes as instructed and wound checks activity weight bearing as tolerated on the operative extremity two crutches or walker at all times for weeks mobilize rom as tolerated no strenuous exercise or heavy lifting until follow up appointment physical therapy wbat lle no range of motion restrictions assistive device x weeks post op i e crutches walker mobilize frequently treatments frequency dsd daily prn drainage ice and elevate staples will be removed at your first post operative visit followup instructions

name unit no admission date discharge date date of birth sex f service orthopaedics allergies no known allergies adverse drug reactions attending complaint right knee oa major surgical or invasive procedure right total knee replacement history of present illness year old female with right knee oa failed conservative measures presenting for right tka past medical history hld htn hypothyroidism 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 58am blood hgb hct 05am blood hgb hct 05am blood hgb hct 08pm blood creat 05am blood creat 05am blood creat 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 the patient was bladder scanned for ml and had to be straight catheterized in the pacu she also received two doses of neo in pacu along with ml bolus of fluid for low blood pressure her blood pressure stabilized post interventions pod the patient s creatinine was her toradol was discontinued and both her hctz and lisinopril were held her oxycodone was switched to tramadol due to complaints of dizziness and nausea pod drain was discontinued creatinine was rechecked and was pod creatinine was stable at patient to resume lisinopril hctz upon discharge 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 ms is discharged to home in stable condition no home benefits patient will begin outpatient physical therapy starting on at 2pm medications on admission lisinopril mg po daily atorvastatin mg po qpm hydrochlorothiazide mg po daily levothyroxine sodium mcg po daily discharge medications acetaminophen mg po q8h aspirin ec mg po bid docusate sodium mg po bid gabapentin mg po tid pantoprazole mg po q24h continue while on week course of aspirin mg twice daily senna mg po bid tramadol mg po q4h prn pain moderate atorvastatin mg po qpm hydrochlorothiazide mg po daily levothyroxine sodium mcg po daily lisinopril mg po daily discharge disposition home 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 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 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 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 m service surgery allergies penicillins vancomycin cephalosporins lyrica pyridium attending chief complaint symptomatic cholelithiasis major surgical or invasive procedure laparoscopic cholecystectomy history of present illness mr is a w history of prostate cancer gerd c b thoracic aa htn who presents with epigastric abdominal pain in the setting of known gallstones acs is consulted for evaluation and management of symptomatic cholelithiasis pt reports his pain began suddenly at midnight on the day of presentation pain is described as sharp constant localized to the epigastrum w occasional ruq pain and no radiation he also complains of episodes of nonbloody emesis and nonbloody loose stools this am he has not tolerated po today denies fever chills no sick contacts or new food exposures of note pt had a similar episode of epigastric pain prompting ed evaluation on with ruq u s showing gallstones without evidence of cholecystitis past medical history prostate cancer detected by elevated psa on active surveillance with routine biopsies ascending thoracic aortic aneurysm depression hypertension low back pain obstructive sleep apnea pre diabetes right open tibial fracture asteatotic eczema latent tb never treated posterior vitreous detachment od cataracts esophagus inguinal hernia h o clostridium difficile social history family history father died of prostate cancer at had cad s p cabg and esrd mother with hypertension physical exam gen awake and alert cv rrr resp ctab abd soft appropriately tender nondistended incisions clean dry dressings intact mild serasanguinous staining on epigastric port site extremities wwp pertinent results agap comments glucose if fasting normal provisional diabetes ca mg p alt ap tbili alb ast ldh dbili tprot lip n l m e bas absneut abslymp absmono abseos absbaso ptt inr brief hospital course mr was admitted on under the acute care surgery service for management of her acute cholecystitis he was taken to the operating room and underwent a laparoscopic cholecystectomy please see operative report for details of this procedure he tolerated the procedure well and was extubated upon completion he was subsequently taken to the pacu for recovery he was transferred to the surgical floor hemodynamically stable his vital signs were routinely monitored and he remained afebrile and hemodynamically stable he was initially given iv fluids postoperatively which were discontinued when he was tolerating po s his diet was advanced on the morning of pod to regular which he tolerated without abdominal pain nausea or vomiting he was unable to void post operatively and a foley catheter was placed after multiple failed attempts urology was consulted to place the foley catheter he was encouraged to mobilize out of bed and ambulate as tolerated which he was able to do independently her pain level was routinely assessed and well controlled at discharge with an oral regimen as needed on pod he was discharged home with a foley catheter in place he will follow up in clinic and with his home urologist for foley removal medications on admission the preadmission medication list is accurate and complete chlorthalidone mg po daily finasteride mg po daily gabapentin mg po tid metoprolol succinate xl mg po daily omeprazole mg po daily acetaminophen mg po q8h prn pain docusate sodium mg po tid prn constipation discharge medications acetaminophen mg po q8h prn pain amiloride hcl mg po daily bupropion sustained release mg po qam docusate sodium mg po tid prn constipation finasteride mg po daily gabapentin mg po tid metoprolol succinate xl mg po daily omeprazole mg po daily sertraline mg po daily tamsulosin mg po qhs trazodone mg po qhs prn sleep oxycodone immediate release mg po q4h prn pain rx oxycodone mg tablet s by mouth every hours disp tablet refills aspirin mg po daily chlorthalidone mg po daily multivitamins tab po daily discharge disposition home discharge diagnosis symptomatic cholelithiasis 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 symptomatic gallstones you were taken to the operating room and had your gallbladder removed laparoscopically you tolerated the procedure well and are now being discharged home to continue your recovery with the following instructions please follow up in the acute care surgery clinic at the appointment listed below foley catheter you had difficulty urinating after your surgery a foley catheter had to be placed in your bladder to help with this it was difficulty to put in and it will stay in for one week you will follow up with urology and they will tell you when to remove this activity o do not drive until you have stopped taking pain medicine and feel you could respond in an emergency o you may climb stairs o you may go outside but avoid traveling long distances until you see your surgeon at your next visit o don t lift more than lbs for weeks this is about the weight of a briefcase or a bag of groceries this applies to lifting children but they may sit on your lap o you may start some light exercise when you feel comfortable o you will need to stay out of bathtubs or swimming pools for a time while your incision is healing ask your doctor when you can resume tub baths or swimming how you may feel o you may feel weak or washed out for a couple of weeks you might want to nap often simple tasks may exhaust you o you may have a sore throat because of a tube that was in your throat during surgery o you might have trouble concentrating or difficulty sleeping you might feel somewhat depressed o you could have a poor appetite for a while food may seem unappealing o all of these feelings and reactions are normal and should go away in a short time if they do not tell your surgeon your incision o tomorrow you may shower and remove the gauzes over your incisions under these dressing you have small plastic bandages called steri strips do not remove steri strips for weeks these are the thin paper strips that might be on your incision but if they fall off before that that s okay o your incisions may be slightly red around the stitches this is normal o you may gently wash away dried material around your incision o avoid direct sun exposure to the incision area o do not use any ointments on the incision unless you were told otherwise o you may see a small amount of clear or light red fluid staining your dressing or clothes if the staining is severe please call your surgeon o you may shower as noted above ask your doctor when you may resume tub baths or swimming your bowels o constipation is a common side effect of narcotic pain medications if needed you may take a stool softener such as colace one capsule or gentle laxative such as milk of magnesia tbs twice a day you can get both of these medicines without a prescription o if you go hours without a bowel movement or have pain moving the bowels call your surgeon pain management o it is normal to feel some discomfort pain following abdominal surgery this pain is often described as soreness o your pain should get better day by day if you find the pain is getting worse instead of better please contact your surgeon o you will receive a prescription for pain medicine to take by mouth it is important to take this medicine as directed o do not take it more frequently than prescribed do not take more medicine at one time than prescribed o your pain medicine will work better if you take it before your pain gets too severe o talk with your surgeon about how long you will need to take prescription pain medicine please don t take any other pain medicine including non prescription pain medicine unless your surgeon has said its okay o if you are experiencing no pain it is okay to skip a dose of pain medicine o remember to use your cough pillow for splinting when you cough or when you are doing your deep breathing exercises if you experience any of the following please contact your surgeon sharp pain or any severe pain that lasts several hours pain that is getting worse over time pain accompanied by fever of more than a drastic change in nature or quality of your pain medications take all the medicines you were on before the operation just as you did before unless you have been told differently if you have any questions about what medicine to take or not to take please call your surgeon followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies no known allergies adverse drug reactions attending chief complaint dizziness chest pain major surgical or invasive procedure none history of present illness mr is a with hx of hep b hep c cirrhosis recurrent hcc c b non occlusive pvt colon ca iiib in remission and atrial fibrillation who presented this evening with cp and dizzyness x1 week the patient states that he has had cp over the past week intermittently but that it has worsened and become constant over the past few days no fevers chronic cough no palpitations no vomiting no diarrhea describes anorexia which has been ongoing associated with his cirrhosis positional lightheadedness the patient has undergone a number of medication changes recently he was recently started on spironolactone for ascites and hypokalemia on the patient was scheduled for rfa ablation prior to the procedure he was noted to be in rapid afib new for him it appears the procedure was aborted and the patient was managed with iv metoprolol then sent home on po metoprolol his amlodipine was stopped felt dizzy after returning home and stopped taking spironolactone in the ed the patient was evaluated for acs and pe ctpe was without evidence of pe ecg showed nsr without ischemic change and trop was flat k noted to be low at also found to be orthostatic started on k repletion on arrival to the floor patient states through son who speaks that he feels a bit better chest pain mostly resolved still some dizziness especially when sitting up past medical history oncologic history colon cancer stage iiib t3 n1c m0 kras w t msi stable by mr liver revealed a cirrhotic liver with cm lesion in segment vii suspicious for hcc but not meeting strict optn 5a criteria as well as possible cholecystitis presented with brbpr colonoscopy revealed a cm bleeding mass at cm in the sigmoid colon biopsies revealed adenocarcinoma ct torso that day showed perforated cholecystitis a sigmoid colon mass a cm hepatic lesion suspicious for hcc an adrenal adenoma and possible mesenteric vasculitis underwent sigmoid colectomy and ccy colectomy revealed low grade adenocarcinoma pt2 pn1c with lns sampled and negative for disease but with mesenteric deposits of disease n1c margins widely negative lvi present pni present infiltrating lymphocytes present kras w t and msi stable by ihc c1d1 folfox6 c1d15 mfolfox removed bolus and added neulasta for neutropenia and thrombocytopenia past medical history hepatitis b hepatitis c history of hepatitis e infection hepatocellular carcinoma presumed diagnosed in status post resection in in presumed hepatocellular carcinoma new not recurrence in segment vii discovered in mri cirrhosis complicated by upper gi bleeding from portal hypertensive gastropathy and thrombocytopenia hypertension hyperlipidemia gerd hearing loss sigmoid adenocarcinoma acute cholecystitis complicated by perforation and subhepatic abscess social history family history non contributory physical exam admission exam vs ra general lying in bed nad heent mmm op clear cv rrr s1 and s2 no m r g lung ctab no w r r abd soft nt nd ext no c c e skin no rash neuro alert and oriented cn ii xii intact strength throughout smile symmetric discharge exam vs po r lying ra gen nad cachexic appearing elderly male heent perrla mmm no lad no jvd neck supple no cervical supraclavicular or axillary lad cards rr s1 s2 normal no murmurs gallops rubs pulm ctab no crackles or wheezes abd bs soft nt no rebound guarding no hsm no sign extremities wwp no edema dps pts skin no rashes or bruising neuro aox3 cns ii xii intact strength in u l extremities sensation intact to lt gait deferred this morning pertinent results admission labs 50pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 50pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 50pm blood plt ct 50pm blood glucose urean creat na k cl hco3 angap 50pm blood alt ast alkphos totbili 50pm blood probnp 50pm blood ctropnt 37am blood ctropnt 50pm blood albumin calcium phos mg 50pm blood d dimer 25pm blood po2 pco2 ph caltco2 base xs 09pm blood k 25pm blood lactate imaging cxr findings mild basilar atelectasis is seen without definite focal consolidation there is no pleural effusion the cardiac and mediastinal silhouettes are similar compared to scout radiograph from impression mild basilar atelectasis without definite focal consolidation the cardiac silhouette is borderline to mildly enlarged no pulmonary edema cta chest impression subsegmental pulmonary arterial branches are not well evaluated due to respiratory motion particularly in the lower lobes no evidence of pulmonary embolism seen elsewhere no acute aortic dissection moderate centrilobular and paraseptal emphysema is overall stable from the recent prior exam bibasilar atelectasis without focal consolidation or pleural effusion mediastinal lymph nodes are grossly stable ruq us impression the common bile duct is mildly dilated however may be partially explained as the patient is status postcholecystectomy there is no intrahepatic biliary dilation a x cm predominantly hypoechoic lesion with central echogenicity is consistent with the rfa ablation site main portal vein is patent with hepatopetal flow but attenuated mild splenomegaly discharge labs 25am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 25am blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 25am blood plt ct 25am blood ptt 25am blood glucose urean creat na k cl hco3 angap 25am blood alt ast alkphos totbili 25am blood albumin calcium phos mg with hep b hep c cirrhosis recurrent hcc c b non occlusive pvt colon ca iiib in remission and atrial fibrillation who p w cp and dizziness x1 week now found to be hypokalemic and orthostatic most likely related to anorexia and medication changes acs was ruled out on admission patient found to be orthostatic and bradycardic both of which were thought to be contributing to symptoms patient received iv fluids and electrolyte repletion with significant improvement he was seen by nutrition and multivitamin was added patient was able to take adequate po during admission with regards to his bradycardia patient was recently started on metoprolol for new atrial fibrillation on the medication his heart rate was in s we held the medication and he remained in sinus rhythm with rates in s patient discharged to home with close pcp and cardiology follow up transitional issues patient s metoprolol held during admission and on discharge in setting of bradycardia and dizziness patient in nsr throughout admission consider resuming this medicine as outpatient patient has newly diagnosed atrial fibrillation although currently in sinus as above chadsvasc pcp cardiologist should discuss risks and benefits of anticoagulation as outpatient patient recently stopped taking spironolactone dr will determine when if this medication should be re started in the outpatient setting patient experienced atypical chest pain prior to admission acs ruled out but patient should follow up with cardiology and stress test may be considered patient s qtc noted to be prolonged during admission this should be monitored in outpatient setting medications on admission the preadmission medication list is accurate and complete losartan potassium mg po daily metoprolol succinate xl mg po daily omeprazole mg po daily spironolactone mg po daily tenofovir disoproxil viread mg po daily docusate sodium mg po bid senna mg po bid prn constipation discharge medications multivitamins tab po daily docusate sodium mg po bid losartan potassium mg po daily omeprazole mg po daily senna mg po bid prn constipation tenofovir disoproxil viread mg po daily held metoprolol succinate xl mg po daily this medication was held do not restart metoprolol succinate xl until instructed by your doctor held spironolactone mg po daily this medication was held do not restart spironolactone until instructed by your doctor discharge disposition home discharge diagnosis primary diagnosis orthostatic hypotension hypokalemia secondary to poor po intake secondary diagnosis hepatocellular carcinoma atrial fibrillation 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 admitted to the hospital you were admitted because of dizziness and chest pain what was done for me in the hospital you had tests that determined you were not having a heart attack we gave you iv fluids because you were dehydrated you were seen by a nutritionist who recommended you drink ensure along with your meals and take multivitamin we stopped your metoprolol because your heart rate was low what should i do at home you should not take the metoprolol until directed to do so by your doctor should follow up with a cardiologist for your chest pain they will likely recommend a stress test to determine if you have underlying heart disease you should continue to eat and drink regularly at home and consider supplementing your meals with ensure this will prevent you from becoming dehydrated and dizzy please schedule a follow up appointment with your primary care doctor and within the next weeks please schedule an appointment with cardiology to discuss your chest pain and atrial fibrillation we wish you all the best sincerely your care team followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies no known allergies adverse drug reactions attending chief complaint chest pain hypokalemia major surgical or invasive procedure none history of present illness mr is a with hx of hep b hep c cirrhosis recurrent hcc c b non occlusive pvt colon ca iiib in remission and atrial fibrillation who presented this evening with cp and dizzyness x1 week the patient states that he has had cp over the past week intermittently but that it has worsened and become constant over the past few days no fevers chronic cough no palpitations no vomiting no diarrhea describes anorexia which has been ongoing associated with his cirrhosis positional lightheadedness the patient has undergone a number of medication changes recently he was recently started on spironolactone for ascites and hypokalemia on the patient was scheduled for rfa ablation prior to the procedure he was noted to be in rapid afib new for him it appears the procedure was aborted and the patient was managed with iv metoprolol then sent home on po metoprolol his amlodipine was stopped felt dizzy after returning home and stopped taking spironolactone in the ed the patient was evaluated for acs and pe ctpe was without evidence of pe ecg showed nsr without ischemic change and trop was flat k noted to be low at also found to be orthostatic started on k repletion on arrival to the floor patient states through son who speaks that he feels a bit better chest pain mostly resolved still some dizziness especially when sitting up past medical history oncologic history colon cancer stage iiib t3 n1c m0 kras w t msi stable by mr liver revealed a cirrhotic liver with cm lesion in segment vii suspicious for hcc but not meeting strict optn 5a criteria as well as possible cholecystitis presented with brbpr colonoscopy revealed a cm bleeding mass at cm in the sigmoid colon biopsies revealed adenocarcinoma ct torso that day showed perforated cholecystitis a sigmoid colon mass a cm hepatic lesion suspicious for hcc an adrenal adenoma and possible mesenteric vasculitis underwent sigmoid colectomy and ccy colectomy revealed low grade adenocarcinoma pt2 pn1c with lns sampled and negative for disease but with mesenteric deposits of disease n1c margins widely negative lvi present pni present infiltrating lymphocytes present kras w t and msi stable by ihc c1d1 folfox6 c1d15 mfolfox removed bolus and added neulasta for neutropenia and thrombocytopenia past medical history hepatitis b hepatitis c history of hepatitis e infection hepatocellular carcinoma presumed diagnosed in status post resection in in presumed hepatocellular carcinoma new not recurrence in segment vii discovered in mri cirrhosis complicated by upper gi bleeding from portal hypertensive gastropathy and thrombocytopenia hypertension hyperlipidemia gerd hearing loss sigmoid adenocarcinoma acute cholecystitis complicated by perforation and subhepatic abscess social history family history non contributory physical exam admission exam vs ra general lying in bed nad heent mmm op clear cv rrr s1 and s2 no m r g lung ctab no w r r abd soft nt nd ext no c c e skin no rash neuro alert and oriented cn ii xii intact strength throughout smile symmetric discharge exam vs 95ra oriented x heent sclera anicteric perrl has dentures on top and bottom there is some deterioration of the upper denture without signs of infection no visualiziation of posterior orpharynx cv rrr s1 s2 distant lungs diminished bilaterally no adventitial sounds heard no tenderness to palpation of the chest abdomen soft nt nd extremities no edema bilaterally neurologic cn ii xii grossly intact pertinent results admission labs 15pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 15pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 15pm blood ptt 15pm blood glucose urean creat na k cl hco3 angap 15pm blood alt ast alkphos totbili 15pm blood ctropnt probnp 20am blood ctropnt 15pm blood albumin calcium phos mg 27pm blood d dimer 10pm blood lactate micro urine culture no growth imaging chest xrat impression no acute cardiopulmonary abnormality chest cta impression no evidence of pulmonary embolism or aortic abnormality unchanged moderate upper lobe predominant centrilobular and paraseptal emphysema as well as mild diffuse bronchial wall thickening consistent with chronic airways disease extensive mediastinal lymphadenopathy with at least lymph node larger the prior study cirrhotic liver with numerous subcentimeter hypodensities and a large lesion in hepatic segment vii consistent with known hepatocellular carcinoma ct head impression hypodensity of the right temporal lobe and left occipital lobe are noted without underlying mass effect potentially representing age indeterminate infarcts given the patient s clinical history and without prior imaging for comparison further evaluation with mri with and without contrast given the patient s history of and colon cancer is recommended if there are no contraindications discharge labs 23am blood lactate 45am blood calcium phos mg 45am blood alt ast ld ldh alkphos totbili 45am blood glucose urean creat na k cl hco3 angap 45am blood plt ct 45am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct brief hospital course assessment and plan mr is a year old male with history of hepatitis b hepatitis c cirrhosis c b with hcc and colon cancer stage iiib currently in remission atrial fibrillation now presenting with intermittent chest pains fatigue and poor po intake chest pain unclear etiology with intermittent chest discomfort patient had similar symptoms previously does have some findings concerning for chronic airway disease and some increased mediastinal lymphadenopathy unclear if previously investigated patient did not have symptoms on the floor negative cta for pe or acs ruled out x trops fatigue hemoconcentration malnutrition suspect behind in volume status and increased fatigue to dehydration unclear if specific reason given no significant abdominal pain or other abdominal symptoms however significantly hemoconcentrated with urine spec this improved with volume resuscitation paroxysmal atrial fibrillation found to have bradycardia previously with increased qtc metoprolol held no anticoagulation chads2vasc ekg on arrival was sinus rate control agents were not given due to bradycardia he was discharged with outpatient cardiology follow up dizziness unclear etiology likely to overall dehydration albeit negative orthostatics not classic for other vertigo type sensations no dedicated head imaging in system ct head showed no underlying mass effect however radiology recommended mri but unable to obtain given clip in body recent hepatitis b hepatitis c cirrhosis meld na score now scheduled for rfa ablation in not a candidate for transplantation spironolactone was held due to hypovolemia he was continued on his tenofovir colon cancer stage iiib in remission curative intent adjuvant therapy requiring annual imaging thrombocytopenia related to underlying cirrhosis at this point concentrated with baseline in 60s patient with elevated cr to baseline is suspect dehydration and hypovolemia after resusitation cr trended down hypertension patient takes losartan as outpatient but it was held in setting and normotension it was restarted upon discharge transitional issues chest pain resolved unclear etiology negative cta troponins ecg please monitor for future episodes of chest pain paroxysmal atrial fibrillation sinus rhythm evaluate rhythm and consider need for rate control anticoagulation chads2vasc dizziness unclear etiology mri could not be done due to clip placement in last month can due after colon cancer remission adjuvant therapy with currative intent follow up outpatient onc recommendations malnutrition please encourage him to eat and consider addition of medications to increase appetite if continues to loose weight htn bp within normal limits while admitted please assess need safety of restarting lisinopril cirrhosis held spironolactone due to dehydration held upon discharge please reassess need safety of restarting paf patient s metoprolol held given bradycardia to the hypertension patient has history of hypertension however blood pressures normal despite anti htn being held please re evaluate and restart as needed services patient was set up with elder services upon discharge medications on admission the preadmission medication list is accurate and complete omeprazole mg po daily tenofovir disoproxil viread mg po daily multivitamins tab po daily docusate sodium mg po bid senna mg po bid prn constipation metoprolol succinate xl mg po daily spironolactone mg po daily losartan potassium mg po daily the preadmission medication list is accurate and complete omeprazole mg po daily tenofovir disoproxil viread mg po daily multivitamins tab po daily docusate sodium mg po bid senna mg po bid prn constipation metoprolol succinate xl mg po daily spironolactone mg po daily losartan potassium mg po daily discharge medications docusate sodium mg po bid multivitamins tab po daily omeprazole mg po daily senna mg po bid prn constipation tenofovir disoproxil viread mg po daily discharge disposition home discharge diagnosis primary acute kidney injury atypical chest pain dehydration secondary diagnosis paroxysmal atrial fibrillation hepatitis b hepatitis c cirrhosis colon cancer discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr it was a pleasure caring for you during your stay at you were admitted to the hospital due to dizziness chest pain and kidney damage due to dehydration while you were in the hospital you received fluids which improved your kidney function to assess your dizziness a ct scan which was negative for any acute issues your chest pain resolved while in the hospital and ekg and blood work showed the pain was not from your heart you will have follow up with your interventional radiology team tomorrow on for rfa ablation please follow up with your liver specialists and your primary care physician please continue to take all of your home medications as prescribed best 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 s p tace major surgical or invasive procedure transarterial chemoembolization findings conventional celiac and hepatic arterial anatomy pre embolization arteriogram and cone beam ct showing tumor blush in segment vi post embolization showing staining of tumor in segment vi with inflow arterial stasis impression successful left greater artery approach trans arterial chemoembolization of hcc located in segment vi history of present illness this is a male with colon cancer t3 n1 m0 s p resection on and folfox hcv hbv cirrhosis compensated with hepatocellular carcinoma status post multiple rfa admitted s p tace for cm segment vi hcc recurrence he presented today for planned transcatheter arterial chemoembolization with left radial access he received 1l ns fentanyl and oxycodone he tolerated the procedure well in the pacu he was note to be wheezing and was given a neb from which he improved on arrival to the floor he reports feeling well history is obtained with interpreter and son s assistance the patient is not able to confirm the date or specify which hospital he is in which the son reports is his usual he reports no pain no trouble with breathing no chest discomfort ros per hpi otherwise rest of 10pt review negative past medical history past oncologic history hepatocellular carcinoma in the setting of hcv hbv and possible alcoholic cirrhosis resection of a primary hcc by report presented with worsening abdominal pain egd revealed grade i varices and a gastric ulcer mr liver revealed a cirrhotic liver with cm lesion in segment vii suspicious for hcc but not meeting strict optn 5a criteria as well as possible cholecystitis mr liver showed a x cm segment vii hepatic lesion is unchanged in size since however now meets optn 5a criteria for hcc new x cm arterially hyperenhancing segment viii lesion does not meet strict optn criteria but is suspicious for hcc rfa of the larger segment viii lesion mr liver showed full treatment of the segment viii lesion stable segment vii lesion ct torso showed the arterial hyperenhancing lesion in segment viii does not demonstrate washout and does not meet criteria for an optn lesion however has grown in size compared with the prior study measuring cm previously cm interval increase size of a low density lymph node with internal calcification posterior to the ivc and a small aortocaval lymph node pet scan is recommended pet ct torso showed a cm arterially enhancing lesion within segment vii shows subtle washout on delayed imaging and is consistent with hepatocellular carcinoma optn class 5b new portal vein thrombosis and evidence of portal hypertension no metastatic disease rfa to his recurrent hcc ct abdomen showed a cm segment vi hcc by optn mr liver revealed a cirrhotic liver with cm lesion in segment vii suspicious for hcc but not meeting strict optn 5a criteria as well as possible cholecystitis presented with brbpr colonoscopy revealed a cm bleeding mass at cm in the sigmoid colon underwent sigmoid colectomy and ccy c1d1 folfox6 c2d1 modified folfox no bolus lv mg m2 oxaliplatin mg m2 neulasta delayed and reduced for cytopenias and liver injury dose of chemotherapy held for diarrheal illness attributed to food poisoning v viral infection holding further chemo for past toxicity ct torso mr liver showed a x cm segment vii hepatic lesion is unchanged in size since however now meets optn 5a criteria for hcc colonoscopy with poor prep at least one adenoma identified and removed ct torso showed the arterial hyperenhancing lesion in segment viii does not demonstrate washout and does not meet criteria for an optn lesion however has grown in size compared with the prior study measuring cm previously cm interval increase size of a low density lymph node with internal calcification posterior to the ivc and a small aortocaval lymph node pet scan is recommended pet ct torso showed a cm arterially enhancing lesion within segment vii shows subtle washout on delayed imaging and is consistent with hepatocellular carcinoma optn class 5b new portal vein thrombosis and evidence of portal hypertension no metastatic disease colonoscopy showed polyps gi recommended repeat in years ct abdomen showed a cm segment vi hcc by optn criteria no metastatic disease social history family history non contributory physical exam admission physical exam t bp hr rr o2 ra gen elderly man in no acute distress breathing slightly labored heent moist membranes anicteric neck no masses heart rrr no murmurs lungs insp expiratory wheeze slightly labored breathing but comfortable abd soft nontender nondistended no fluid wave gu no foley ext warm no edema neuro prominent asterixis alert oriented to self and hospital only discharge pe vs t bp hr rr o2 sat ra gen nad resting interpretation with son eyes no scleral icterus hent ncat trachea midline cv rrr s1 s2 no m r r g no edema ble lungs cta b no w r r c gi bs soft nttp nd no grimace to palpation with ruq gu no foley msk strength bilaterally intact rom neuro moving all extremities no focal deficits a o to place hospital but not year never knows year knows time but not exact date which is baseline knows birthday and oriented to situation person skin no rash or ecchymosis psych congruent affect good judgment pertinent results admission labs 45pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 45pm blood 45pm blood glucose urean creat na k cl hco3 angap 40am blood alt ast alkphos totbili 40am blood cea afp discharge labs 50am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 30am blood glucose urean creat na k cl hco3 angap 30am blood alt ast alkphos totbili ct a p pending read will f u with hepatologist for results brief hospital course assessment and plan this is a male with colon cancer t3 n1 m0 s p resection on and folfox hcv hbv cirrhosis compensated with hepatocellular carcinoma status post multiple rfa admitted s p tace for cm segment vi hcc recurrence s p tace hcc recurrent tolerated tace well minimal pain at present abd exam benign noncontrast ct done pending read will f u with hepatologist on results pain and nausea is controlled at time of discharge acute encephalopathy post procedure but resolved with sleep overnight pt is at baseline orientation per family knows place situation dob people location but not date year month which is normal wheeze active smoker cxr without evidence of aspiration or fluid overload from ivf during procedure breathing comfortably f u with pcp if copd is a possibility and pfts hypokalemia k repleted with meq and meq iv with discharge k hcv hbc cirrhosis has asterixis unclear if this is baseline or triggered by anesthesia not on hepatic encephalopathy meds improved in am likely post anesthesia effect cont tenofovir 300mg daily essential htn controlled restart losartan 100mg daily code presumed full discharge to home without services pt met inpatient criteria with k and encephalopathy post procedure he improved faster than expected minutes was spent on this discharge with coordinating follow up discussing with son interpretation and communication with medications on admission the preadmission medication list is accurate and complete docusate sodium mg po bid multivitamins tab po daily omeprazole mg po daily senna mg po bid prn constipation tenofovir disoproxil viread mg po daily losartan potassium mg po daily discharge medications docusate sodium mg po bid losartan potassium mg po daily multivitamins tab po daily omeprazole mg po daily senna mg po bid prn constipation tenofovir disoproxil viread mg po daily discharge disposition home discharge diagnosis post tace hcc acute encephalopathy resolved hypokalemia resolved wheezing no o2 requirements abdominal pain resolved hbv hcv cirrhosis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions mr you were admitted for a transarterial chemoembolization of your liver cancer the procedure went well you were slightly confused after the procedure but that has cleared this morning you could expect to have low grade fevers abdominal pain in your right upper abdomen and nausea vomiting post this procedure please check in with your hepatologist if these occur for instructions you had a ct scan of your belly to see the end results of your embolization you will have the results when you follow up with your hepatologist 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 new metastatic lesions major surgical or invasive procedure guided lung biopsy history of present illness pmh hcc s p liver resection rfa as well as colon cancer s p resection adjuvant folfox presents today with new metastatic lesions on imaging acute pe as per review of clinic notes pt last seen in when he was felt to be in remission for colon cancer but afp was rising subsequent ct was without evidence of new or recurrent disease on patient had colonoscopy without any e o malignancy today patient had ct scans which revealed new liver lesions which appeared more c w colorectal metastases and was also found to have apply core lesion in neo sigmoid colon c f malignancy ct chest revealed rll pe numerous b l lung nodules c w metastatic disease as well as new thyroid nodules in light of new malignant lesions patient referred to ed by outpatient oncologist for expedited w u including biopsy to determine if lesions are due to hcc or colon cancer recurrence pt reports that he has some shortness of breath but is without any chest pain or pleurisy he noted that he feels wheezy denied any cough fever or chills he noted that he has intermittent constipation and is only been passing small bowel movements which she is concerned about noted that he is tolerating oral intake and is voiding without difficulty he noted that he is concerned about the cancerous lesions and is hopeful that there is a treatment in the ed initial vitals ra hgb plt wbc wnl chem w hco3 lactate inr cth no acute intracranial process mild small vessel disease no definite intracranial mets patient was admitted for expedited workup with biopsy past medical history past oncologic history hepatocellular carcinoma in the setting of hcv hbv and possible alcoholic cirrhosis resection of a primary hcc by report presented with worsening abdominal pain egd revealed grade i varices and a gastric ulcer mr liver revealed a cirrhotic liver with cm lesion in segment vii suspicious for hcc but not meeting strict optn 5a criteria as well as possible cholecystitis mr liver showed a x cm segment vii hepatic lesion is unchanged in size since however now meets optn 5a criteria for hcc new x cm arterially hyperenhancing segment viii lesion does not meet strict optn criteria but is suspicious for hcc rfa of the larger segment viii lesion mr liver showed full treatment of the segment viii lesion stable segment vii lesion ct torso showed the arterial hyperenhancing lesion in segment viii does not demonstrate washout and does not meet criteria for an optn lesion however has grown in size compared with the prior study measuring cm previously cm interval increase size of a low density lymph node with internal calcification posterior to the ivc and a small aortocaval lymph node pet scan is recommended pet ct torso showed a cm arterially enhancing lesion within segment vii shows subtle washout on delayed imaging and is consistent with hepatocellular carcinoma optn class 5b new portal vein thrombosis and evidence of portal hypertension no metastatic disease rfa to his recurrent hcc ct abdomen showed a cm segment vi hcc by optn mr liver revealed a cirrhotic liver with cm lesion in segment vii suspicious for hcc but not meeting strict optn 5a criteria as well as possible cholecystitis presented with brbpr colonoscopy revealed a cm bleeding mass at cm in the sigmoid colon underwent sigmoid colectomy and ccy c1d1 folfox6 c2d1 modified folfox no bolus lv mg m2 oxaliplatin mg m2 neulasta delayed and reduced for cytopenias and liver injury dose of chemotherapy held for diarrheal illness attributed to food poisoning v viral infection holding further chemo for past toxicity ct torso mr liver showed a x cm segment vii hepatic lesion is unchanged in size since however now meets optn 5a criteria for hcc colonoscopy with poor prep at least one adenoma identified and removed ct torso showed the arterial hyperenhancing lesion in segment viii does not demonstrate washout and does not meet criteria for an optn lesion however has grown in size compared with the prior study measuring cm previously cm interval increase size of a low density lymph node with internal calcification posterior to the ivc and a small aortocaval lymph node pet scan is recommended pet ct torso showed a cm arterially enhancing lesion within segment vii shows subtle washout on delayed imaging and is consistent with hepatocellular carcinoma optn class 5b new portal vein thrombosis and evidence of portal hypertension no metastatic disease colonoscopy showed polyps gi recommended repeat in years ct abdomen showed a cm segment vi hcc by optn criteria no metastatic disease social history family history non contributory physical exam general lying in bed appears comfortable son at bedside eyes pupils equally round anicteric heent oropharynx clear moist mucous membranes neck neck supple normal range of motion lungs wheezing plus rhonchi left mid to lower lobe respiratory rate was normal patient without increased work of breathing rll biopsy site dressing c d i cv regular rate and rhythm no murmurs rubs or gallops abd soft distended resonant to percussion nontender no rebound or guarding genitourinary no foley ext decreased muscle bulk moving all extremities spontaneously skin warm dry no rash neuro alert and oriented x3 fluent speech access peripheral iv pertinent results 28pm creat 35pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 46pm ptt 50pm lactate 05am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 00am blood ptt 05am blood glucose urean creat na k cl hco3 angap 00am blood alt ast alkphos totbili 05am blood calcium phos mg 15am blood cea ct a p impression new optn b lesions in segment ii v and vi a new enhancing mass in segment vi is not hyperenhancing on the arterial phase and maintains persistent enhancement with an appearance more characteristic of colorectal metastasis than hepatocellular carcinoma by imaging re demonstrated treatment cavities in segment vii and viii without evidence of local recurrence treatment cavity in segment vi is re demonstrated with some enhancement but no definite washout and overall the appearance is similar to prior continued attention on follow up is recommended nonocclusive thrombosis in the left portal vein stable splenomegaly with new moderate volume ascites new cm long apple core lesion in the neo sigmoid colon is concerning for malignancy recommend correlation with direct visualization please refer to the separately dictated ct chest report from the same date for a description of thoracic findings chest ct impression right lower lobe subsegmental pulmonary arterial filling defects compatible with recent pulmonary emboli new since the prior study numerous bilateral lung nodules new since are likely metastases bilateral hypodense nodules in the thyroid measure up to cm on the right further evaluation with thyroid ultrasound is recommended if clinically appropriate please see separately submitted abdomen and pelvis ct report for subdiaphragmatic findings ct head impression no acute intracranial process mild small vessel disease no definite evidence for intracranial metastasis there is further concern an mri may be performed to further assess colonoscopy colonic mucosa appeared normal prep was fair the sigmoid colon was thoroughly evaluated with the therapeutic egd scope and then with a standard egd scope no mass was seen a circumferentially thickened fold was seen in the distal sigmoid at the site of the anastomosis but otherwise appeared normal the anastomosis was seen on tretroflexion and appeared normal the thickened sigmoid fold possibly may have caused the ct findings the lumen was not obstructing and was widely patent and hence a colonic stent was not placed indicated brief hospital course pmh hcc s p liver resection rfa as well as colon cancer s p resection adjuvant folfox presents today with new metastatic lesions on imaging acute pe also with significant obstructive bowel sx s p he was started on heparin drip for pe guided biopsy of lung was performed and results pending he underwent which did not show an obstructive lesion after which his obstructive bowel symptoms improved he is resumed on lovenox for pe and is stable for discharge with onc follow up medications on admission the preadmission medication list is accurate and complete albuterol inhaler puff ih q6h prn sob tenofovir disoproxil viread mg po daily omeprazole mg po daily amlodipine mg po daily discharge medications enoxaparin sodium mg sc q12h start first dose next routine administration time rx enoxaparin mg ml mg subq every twelve hours disp syringe refills polyethylene glycol g po daily rx polyethylene glycol miralax gram dose g by mouth daily refills senna mg po daily rx sennosides mg tab by mouth daily disp tablet refills albuterol inhaler puff ih q6h prn sob omeprazole mg po daily tenofovir disoproxil viread mg po daily discharge disposition home discharge diagnosis metastatic cancer of unknown primary history of liver cancer history of colon cancer acute pulmonary embolism discharge condition fair a ox3 self ambulatory without assist discharge instructions dear were admitted to the hospital after your oncologist found new cancer lesions in your colon liver thyroid and lungs your lung lesion is biopsied and the results are pending also were found to have a pulmonary embolism and need to take a blood thinner shot twice a day 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 bright red blood in stools major surgical or invasive procedure none history of present illness pcp cc bleeding history of present illness mr is a with history of htn hld crc s p sigmoidectomy folfox and hcv hbv c b cirrhosis and hcc s p resection adjuvant chemo c b recurrence and lung mets who presents with brbpr in setting of anticoagulation for recent pe history taken from son and chart mr was discharged from for hospitalization where he was found to have metastatic hcc to the lung as well as new pe he was discharged on days of lovenox with instructions to switch to apixaban on son reports that patient only just filled the apixaban script prior to presenting to the ed on and has not been taking any anticoagulation since his lovenox ran out on by report the patient has been experiencing rectal urgency and tenesmus for the last days days pta he began noticing blood in the toilet bowl since then he has been having very small bowel movements per day all with bright red blood he denies pain with defecation lightheadedness or presyncope and his appetite is minimal at baseline he endorses episodes of non bloody emesis toward the end of his second episode he had streaks of emesis but no frank blood he denies generalized itchiness and his son reports he does not look more jaundiced than usual he reports days of mild hemoptysis that he attributed to his lung met but he has not had any hemoptysis since the rectal bleeding began yesterday morning in the ed he began experiencing right frontal headaches that are non positional and do not change withneck flexion as well as mild lower abdominal suprapubic pain he had a paracentesis with removal 4l negative for sbp pmns since then his son reports that his abdominal swelling has slowly re accumulated but is not as tense or distended as it was prior to the paracentesis he does not get regular paracenteses in the ed vitals were t hr bp rr o2 sat ra exam no acute distress rrr no m r g lungs ctab distended abdomen w ascites nontender no spider angiomas nail changes no asterixis labs cbc wbc hb from nadir of plt bmp na k cl hco3 bun cr ca mg ph lft alt ast ap tbili alb lactate ua with urobilinogen otherwie unremarkable ucx pending studies colonoscopy internal hemorrhoids no active bleeding also showed small angiodysplasia and submucosal mass ruqus cirrhotic liver morphology with heterogeneous echotexture and multiple masses compatible with known malignancy these masses are better evaluated on the previously performed ct abdomen pelvis nonocclusive thrombus in the main portal vein with reversal flow main portal vein velocity is cm s reversal of normal directional flow in the right portal vein there is appropriate directional flow in the left portal vein moderate volume ascites in all abdominal quadrants splenomegaly he was given for gib 2l lr ctx 1g iv ppx for bp home amlodipine he also got fleet enema in preparation for his colonoscopy on arrival to the floor patient reports that he has headache which is improved compared to the ed he also reports a little abdominal discomfort and fullness he feels cold which is his baseline he does not have any dizziness or lightheadedness he does not have any blurred vision palpitations or shortness of breath he denies any fever chills or sweats no abdominal pain his last bowel movement was in the evening he has not had anything to drink for most of the day past medical history hcv hbv cirrhosis hcc s p resection and rfa c b recurrence and lung mets colon ca stage 3b kras s p sigmoid colectomy and adjuvant chemo acute cholecystitis s p ccy htn dyslipidemia gerd hearing loss social history family history no pertinent family history physical exam admission physical exam vitals t hr bp rr spo2 ra general alert and interactive in no acute distress heent perrl eomi mmm sclera and soft palate are icteric bilateral hearing aids in place wearing glasses neck no cervical lymphadenopathy no jvd cardiac regular rhythm normal rate audible s1 and s2 no murmurs rubs gallops lungs clear to auscultation bilaterally no wheezes rhonchi or rales no increased work of breathing back no cva tenderness abdomen normal bowels sounds no organomegaly abdomen is visibly distended with shifting dullness to percussion no tenderness to deep palpation in quadrants or suprapubic extremities no clubbing cyanosis or edema pulses dp radial bilaterally skin diffusely jaundiced with some palmar erythema no spider angiomata warm cap refill 2s no rash neurologic aox3 but confused about longterm history defers to son moving all limbs spontaneously cn2 intact normal sensation no asterixis discharge physcial exam hr data last updated temp tm bp hr rr o2 sat o2 delivery ra general nad son at bedside cardiac rrr nml s1 s2 no mrg lungs on ra ctab abdomen well healed scar in ruq from prior procedure firm particularly in ruq mildly distended no ttp extremities trace skin diffusely jaundiced in lower extremities neurologic awake not oriented to time per son this is baseline no focal neurologic deficits normal gait pertinent results admission labs 15pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 15pm blood neuts lymphs 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 45am blood calcium phos mg 27am blood caltibc ferritn trf 27am blood igm hav neg 45am blood hbv vl not detect hcv vl not detect 06am blood po2 pco2 ph caltco2 base xs comment green top 24pm blood lactate 13am blood lactate 04am blood lactate 25pm blood lactate 06am blood lactate discharge labs 35am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 35am blood glucose urean creat na k cl hco3 angap micro pm peritoneal fluid peritoneal fluid 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 if applicable fluid culture final no growth anaerobic culture preliminary no growth pm fluid received in blood culture bottles peritoneal fluid fluid culture in bottles pending no growth to date reports peritoneal fluid cytology negative for malignant cells liver u s cirrhotic liver morphology with heterogeneous echotexture and multiple masses compatible with known malignancy these masses are better evaluated on the previously performed ct abdomen pelvis nonocclusive thrombus in the main portal vein with reversal flow main portal vein velocity is cm s reversal of normal directional flow in the right portal vein there is appropriate directional flow in the left portal vein moderate volume ascites in all abdominal quadrants splenomegaly colonoscopy polyps in colon angioectasias in colon internal hemmorhoids previous surgery in colon brief hospital course mr is a y o male patient with hbc hcv cirrhosis c b hcc with newly diagnosed lung mets s p resection rfa to segment viii lesions rfa to recurrent lesion adenocarcinoma of colon s p sigmoid colectomy and folfox and non occlusive l portal vein thrombus who was recently admitted for acute rll subsegmental pe from and re admitted on for brbpr likely internal hemorrhoids given metastatic hcc new lesion c f recurrence of colon adenocarcinoma all c b acute pe palliative care was consulted and family decision was made to make pt dnr dni with plan to transition to home with hospice acute issues rectal bleeding normocytic anemia history of colon cancer s p sigmoid resection in in folfox stage iiib t3n1cm0 new 2cm lesion in neo sigmoid colon ct abd patient presenting with brbpr likely internal hemorrhoids though possibly also rectal varices given cirrhosis colonoscopy notable for internal hemorrhoids non bleeding angioectasias in colon of note patient also restarted apixaban for cancer associated pe but did not take this due to inability to fill the medication he was initially started on hep gtt and apixaban for recent diagnosis of pe but this was discontinued on given ongoing brbpr he continued to have ongoing brbpr but reported this decreased compared to admission he was hemodynamically stable and did not require any transfusions during his hospitalization recent dx pe we discussed the risks of not angicoagulating to which pt s son agreed to stopping anticoagulation given ongoing brbpr decompensated cirrhosis c b coagulopathy s p liver resection in history of hbc and hcv patient has a long h o cirrhosis viral hepatitis hcv and hbv and c b hcc has historically been well compensated but presents now in decompensation i s o hyperbilirubinemia elevated lfts and tumor markers and coagulopathy he has a h o ascites with last outpatient paracentesis on with removal of 4l studies negative for sbp repeat para on removed 2l fluid while inpatient and studies neg for sbp he was started on po lasix 20mg qd po spironolactone 50mg qd for abd distension discomfort goc after discussion w pall care on decision was made to make pt dnr dni and plan for home with hospice he continues to have repeated episodes of brbpr though appears to have improved after stopping apixaban for pe they prefer to have a hospice agency that works with pts dnr dni as of molst in chart hemoptysis presented with blood tinged sputum during this admission reportedly had this in the past as well likely re starting ac though improving predisposed to bleeding given pt has cirrhosis coagulopathy per pt this resolved elevated lactate on arrival increased to and then back down to with some fluids ua with trace blood and protein wbc but no signs of infection lactate was wnl on chronic issues hcv hbv transaminitis has a nonocclusive thrombus on ruqus continued tenofovir for now given possible flare of hepatitis if stopped cancer associated pain received tylenol up to 2g daily and oxy 5mg prn for pain htn d c ed home amlodipine losartan due to soft pressures sbp 100s gerd continued home omeprazole for discomfort from acid reflux code dnr dni as of molst in chart contact relationship son phone number transitional issues fyi pt is dnr dni molst form in chart signed holding home lenvatinib onc for the time being can consider restarting if within goals of care offers symptomatic support continued viread tenofovir due to concern for possible hepatitis flare if stopped can discontinue if not within goc consider using dark towels wipes suspect he will have ongoing bleeding from rectum medications on admission the preadmission medication list is accurate and complete amlodipine mg po daily apixaban mg po bid lenvima lenvatinib mg oral daily omeprazole mg po daily tenofovir disoproxil viread mg po daily propranolol mg po bid docusate sodium mg po bid losartan potassium mg po daily oxycodone immediate release mg po q6h prn pain moderate discharge medications calcium carbonate mg po qid prn acid reflux furosemide mg po daily lactulose ml po daily prn constipation second line lidocaine patch ptch td qam polyethylene glycol g po daily prn constipation third line senna mg po daily spironolactone mg po daily cirrhosis c b ascites docusate sodium mg po bid omeprazole mg po daily oxycodone immediate release mg po q6h prn pain moderate tenofovir disoproxil viread mg po daily held lenvima lenvatinib mg oral daily this medication was held do not restart lenvima until you discuss with dr disposition home with service facility discharge diagnosis hematochezia internal hemmorhoids acute on chronic anemia colon cancer recent diagnosis pulmonary embolism decompensated cirrhosis coagulopathy hepatocellular carcinoma hemoptysis elevated lactate transaminitis secondary diagnoses hypertension acid reflux history of hep b hep c discharge condition mental status confused sometimes level of consciousness alert and interactive activity status ambulatory independent discharge instructions discharge instructions dear mr it was a privilege caring for you at why was i in the hospital you came to the hospital for blood in your stools what happened to me in the hospital we did a colonoscopy taking a look inside your gut to figure out where the bleeding was coming from the bleeding is due to hemorrhoids dilated veins in your rectum your bleeding improved but you still had some bleeding when you left we had our palliative care doctors they helped arrange home with hospice services hospice is type of care you receive to make people comfortable as they near the end of their lives what should i do after i leave the hospital continue to take all your medicines and keep your appointments please call hospice if you have any questions or concerns we wish you the best sincerely your team followup instructions

name unit no admission date discharge date date of birth sex m service surgery allergies penicillins tetracycline attending chief complaint acute diverticulitis major surgical or invasive procedure none history of present illness man with history of anca positive vasculitis on chronic prednisone who presents to the ed after days of abdominal pain patient reports that he has been having periumbilical bandlike pain since days ago that worsened day ago after a large meal he continues to pass gas his last bowel movement was yesterday and that was normal and he does not endorse nausea vomiting patient reports that his last episode of diverticulitis was in and his last colonoscopy was done to years ago and was negative he is admitted to the ed for evaluation of his acute diverticulitis that was found on ct that shows cm phlegmonous change in the ascending colon no drainable collection he is otherwise feeling well past medical history hypertension hypercholesterolemia anca associated vasculitis wegener s granulomatosis granulomatosis with polyangiitis i do not think he will likely need the medicine bph benign prostatic hyperplasia the patient is having really like seeing the patient because he was cutting the mosaic klinefelter syndrome social history family history no family history of ibd grandfather with colon cancer at age of physical exam gen a o nad heent no scleral icterus mucus membranes moist cv rrr no m g r pulm clear to auscultation b l no w r r abd soft nondistended mildly tender to palpation on the right lower quadrant no rebound or guarding no palpable masses dre normal tone no gross or occult blood ext no edema warm and well perfused pertinent results 40pm glucose urea n creat sodium potassium chloride total co2 anion gap 40pm estgfr using this 40pm alt sgpt ast sgot alk phos tot bili 40pm lipase 40pm albumin 40pm neuts lymphs monos eos basos im absneut abslymp absmono abseos absbaso 40pm plt count 40pm plt count 30pm urine color straw appear clear sp 30pm urine blood neg nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg brief hospital course w h o anca vasculitis on chronic steroid p w acute diverticulitis the patient was placed on iv abx and pain meds the patients pain improved on hd2 on hd3 mr was transitioned to po abx and pain peds he was given a regular diet mr was discharged from the hospital on hd3 in stable condition he was tolearing a regular diet voiding but still mildly tender on abdominal exam he was asked to follow up in clinic and placed on a total of days of cipro flagyl medications on admission acetaminophen mg po q6h prn pain mild reason for prn duplicate override alternating agents for similar severity oxycodone immediate release mg po q4h prn pain moderate rx oxycodone mg capsule s by mouth q6h prn disp capsule refills amlodipine mg po daily lisinopril mg po daily discharge medications acetaminophen mg po q6h prn pain mild reason for prn duplicate override alternating agents for similar severity ciprofloxacin hcl mg po q12h rx ciprofloxacin hcl mg tablet s by mouth every twelve hours disp tablet refills metronidazole mg po q8h rx metronidazole mg tablet s by mouth every eight hours disp tablet refills oxycodone immediate release mg po q4h prn pain moderate rx oxycodone mg capsule s by mouth q6h prn disp capsule refills amlodipine mg po daily lisinopril 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 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 f service medicine allergies ciprofloxacin attending chief complaint cough rhoncherous breathing major surgical or invasive procedure none history of present illness year old with history of advanced dementia bed bound non vocal rarely opens eyes to voice for past few months and seizure disorder presenting with cough and rhoncherous breathing per reports pt was noted to have developed a cough starting on night her cough persisted and on she developed a worsening cough with rhoncherous breathing given her worsening symptoms pt s pcp was called and referral to the to rule out pneumonia was recommended of note pt is taken care of at home by two home health aids one of which was recently exposed to an ili in the initial vital signs were ra exam was notable for pt arousable to painful stimuli baseline she is arousable to voice diffuse rhonchi are symmetric and likely transmitted upper airway sounds no unilateral edema labs were notable for wbc h h plts na k bun cr lfts wnl alb inr probnp troponin lactate ua with wbc many bacteria positive nitrites small leuks epis flu a and b pcr negative imaging cxr with no acute intrathoracic process the patient was given 2l ns azithromycin 500mg iv x consults none vitals prior to transfer were ra upon arrival to the floor pt is at her baseline and unresponsive review of systems negative except as above past medical history acute bronchitis anxiety asthma dementia left bundle branch block urinary tract infection otalgia skin ulcers social history family history no family history of early dementia physical exam exam on admission vitals on ra general unresponsive eventually opened eyes to sternal rub heent normocephalic atraumatic perrla neck supple cardiac regular rate rhythm normal s1 s2 no murmurs rubs or gallops pulmonary rhoncherous upper airway sounds abdomen normal bowel sounds soft non tender non distended no organomegaly extremities warm well perfused no cyanosis clubbing or edema skin without rash neurologic eventually opens eyes to sternal rub exam on discharge vitals ra general at times opens eyes to voice otherwise nonverbal and nonresponsive cardiac regular rate rhythm normal s1 s2 no murmurs rubs or gallops pulmonary breathing is even and unlabored breath sounds less rhoncherous coughing at times pertinent results labs 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 hypochr normal anisocy normal poiklo normal macrocy microcy normal polychr normal 25pm blood ptt 25pm blood glucose urean creat na k cl hco3 angap 25pm blood alt ast alkphos totbili 25pm blood probnp 25pm blood ctropnt 30am blood ck mb ctropnt 25pm blood albumin 30am blood calcium phos mg 31pm blood lactate 50pm blood lactate labs on discharge 30am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 30am blood glucose urean creat na k cl hco3 angap microbiology blood cultures ngtd urine culture klebsiella ampicillin sulbactam s cefazolin s cefepime s ceftazidime s ceftriaxone s ciprofloxacin s gentamicin s meropenem s nitrofurantoin i piperacillin tazo s tobramycin s trimethoprim sulfa s imaging studies cxr ap portable upright view of the chest overlying ekg leads are present mildly elevated right hemidiaphragm again noted there is no focal consolidation effusion or pneumothorax the cardiomediastinal silhouette is normal imaged osseous structures are intact brief hospital course year old female with advanced alzheimer s dementia seizure disorder and asthma presenting with cough and rhoncherous breathing found to have likely uti and possible uri presumed uti and possible uri the patient was found to have a positive ua and an elevated lactate making uti as the most likely etiology of her encephalopathy she was started on ceftriaxone for treatment her cxr did not demonstrate evidence of pneumonia however she was found to have notable rhonchi on exam with secretions suggestive of uri bronchitis given her clinical picture she was also started on a course of azithromycin her lactate began to downtrend and her mental status improved with treatment with the antibiotics following a discussion about hospice care see below the patient was discharged home to complete a five day course of augmentin and azithromycin to complete her treatment advanced dementia goals of care pt has rapidly declined over the past months and is currently bed bound and unresponsive at baseline the patient was made dnr dni on admission her husband expressed interest in hospice care the patient currently has two home aids however neither are trained in medical care palliative care was consulted after a discussion it was decided that the patient would have home hospice care discussed with husband at length the course of end stage dementia and how it is a uniformly fatal disease discussed possible difficulties he and his family may encounter including difficulty with nutrition and hydration and recurrent infections reviewed molst form with husband patient will be dnr dni with transfer to hospital only for comfort seizure disorder pt has a history of generalized seizure in the setting of advanced dementia continued home divalproex transitional issues patient was discharged to complete a day course of azithromycin and augmentin for uti and pneumonia patient was discharged home with hospice and focus is to be on comfort will plan to continue divalproex sprinkles to prevent seizures the need for this can be further discussed with the patient s outpatient providers contact husband hcp code status dnr dni medications on admission the preadmission medication list is accurate and complete divalproex sod sprinkles mg po bid bismuth subsalicylate ml po tid prn indigestion fluticasone propionate 110mcg puff ih bid albuterol sulfate mcg actuation inhalation q6h prn wheezing influenza vaccine quadrivalent ml im now x1 start first dose next routine administration time discharge medications divalproex sod sprinkles mg po bid fluticasone propionate 110mcg puff ih bid amoxicillin clavulanate susp mg po q12h rx amoxicillin pot clavulanate mg mg ml ml by mouth twice a day refills azithromycin mg po q24h rx azithromycin mg tablet s by mouth daily disp tablet refills albuterol sulfate mcg actuation inhalation q6h prn wheezing bismuth subsalicylate ml po tid prn indigestion discharge disposition home with service facility discharge diagnosis primary diagnoses urinary tract infection upper respiratory infection end stage dementia secondary diagnoses skin ulcers anorexia discharge condition mental status confused always level of consciousness lethargic and not arousable activity status bedbound discharge instructions dear ms and family you were admitted with a cough and difficulty breathing and we also found that you have an infection in your urine we treated you with antibiotics we also discussed helping with your care at home including hospice we hope that these services help with keeping you comfortable at home with your family we wish you and your family all the best sincerely your care team followup instructions

name unit no admission date discharge date date of birth sex f service neurology allergies dapagliflozin attending chief complaint abnormal head ct nausea major surgical or invasive procedure none history of present illness mrs is a year old active woman with diabetes type hypertension atrial fibrillation on eliquis mild cognitive decline presumed who presents as hospital to hospital transfer for evaluation of abnormal finding on head ct history obtained by patient and patient s daughter and niece at bedside per patient who digresses quite a bit on conversation she was feeling well up until about days ago when she became nauseous and started to vomit she thought she had a stomach bug because she just was not feeling well at all and didn t even good enough to get up out of bed to dust the tv the patient cannot say if her symptoms suddenly came on she does endorse some double vision when she does not wear her glasses that comes and goes and gets better after she puts her glasses on additional details regarding nausea and vomiting limited as patient continues to digress in conversations her daughter notes that she last saw her mother days ago for she had picked her mother up to celebrate thanksgiving with the family down at the during that week while she was watching her mother throughout the day she noticed that her mother s word finding difficulty was worse and that her appetite was significantly decreased she also noted that her mother s gait was worse wobbling to both the left and the right despite use of a cane the daughter does note that this decline has been ongoing for the past several months however despite this decline the patient is completely independent at home and continues to work hrs a week at stop and shop and continues to drive at night when asked to elaborate on the decline over the last few months the daughter notes a slow decline in the patient s word finding difficulty disorientation to day and month sometimes she also notes a weight loss over the past months ros challenging as patient continues to digress without clarity of specific details regarding timing intensity of symptoms noted she does endorse transient double vision that resolves with wearing glasses nausea that has subsided and denies vertigo she had a frontal throbbing headache but that has since resolved she thinks her gait is steady with her cane her daughter notes that several weeks ago the patient broke out in a rash in her thighs that resolved with a 14d course of doxycycline regarding cancer history risk factors the patient is a former smoker but quit years ago she has never carried a diagnosis of cancer at osh she was noted to be hypochloremic and hypomagnesemic which was corrected with electrolyte repletion past medical history diverticulitis s p surgery diabetes atrial fibrillation hypertension hyperlipidemia bilateral cataract repair bilateral hip repair years ago social history family history sister with skin cancer and then glioblastoma diagnosed at the age of brother with throat cancer and then died of brain tumor years later physical exam vitals t97 hr80 bp119 rr17 98ra glucose general awake cooperative appears younger than stated age heent nc at no scleral icterus noted mmm no lesions noted in oropharynx neck supple no carotid bruits appreciated no nuchal rigidity pulmonary normal work of breathing cardiac irregular rate warm and well perfused abdomen soft non distended extremities trace bipedal edema skin inner thighs with maculopapular rash that appears to be resolving confirmed with daughter that looks better than in prior days neurologic mental status alert oriented to name location hospital in but not but not date able to relate general history but with significant digressions in story taking time to describe how she felt too tired to dust the tv then noting that it didn t matter because they are coming to see her and not the tv and then telling me how kind they are to visit her and proceeding to elaborate on her family support network forward is rapid backwards is slower and the patient only reaches and then digresses she is able to follow two step commands has ocassional paraphasic errors referring to novels regarding the book she likes to read as novelities repetition intact normal prosody able to name both high frequency objects but some errors with low frequency objects no dysarthria able to follow both midline and appendicular commands there was no evidence of apraxia or neglect cranial nerves post cataract surgery bilateral perrl and sluggish eomi no nystagmus no ptosis face appears symmetric hearing diminished to conversation tongue deviates to right uvula deviates to right right pupil dysmetria on left finger motor decreased bulk normal tone no pronator drift no adventitious movements such as tremor or asterixis noted full confrontational strength testing limited largely by best effort but to best of ability patient gives symmetric resistance throughout l r sensory diminished sensation to pinprick in stocking glove pattern light touch temperature vibratory sense intact reflexes plantar response was flexor bilaterally coordination dysmetria on left fnf left hks diminished amplitude with fast movements on left hand gait deferred secondary to fatigue patient refused and absence of cane at bedside no leaning to one side with sitting on bed with eyes closed discharge vitals tm c bp hr rr sao2 general awake nad heent nc at no scleral icterus noted mmm pulmonary breathing comfortably no tachypnea nor increased wob cardiac skin warm well perfused extremities symmetric no edema neurologic mental status awake alert and oriented to person and time but thinks she is at a hospital in attentive able to name forward and backward without difficulty language is fluent with intact comprehension and slightly impaired repetition no ifs ands and buts there were no paraphasic errors naming intact to high and low frequency objects able to follow both midline and appendicular commands cranial nerves perrl eomi without nystagmus facial sensation intact to light touch face symmetric at rest and with activation hearing impaired bilaterally to conversation palate elevates symmetrically tongue protrudes in midline no dysarthria motor decreased bulk no adventitious movements such as tremor noted remainder of exam deferred sensory deferred dtrs coordination no intention tremor no dysdiadochokinesia noted no dysmetria on fnf bilaterally gait patient able to walk evenly with assistance on either side no wide based gait or unsteadiness inconsistent with muscle bulk noted pertinent results 29pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 08am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 29pm blood ptt 40pm blood ptt 08am blood ptt 29pm blood glucose urean creat na k cl hco3 angap 40pm blood glucose urean creat na k cl hco3 angap 40am blood glucose urean creat na k cl hco3 angap 08am blood glucose urean creat na k cl hco3 angap 40pm blood alt ast ld ldh ck cpk alkphos totbili 40pm blood ggt 29pm blood lipase 29pm blood ck mb ctropnt 40pm blood ck mb ctropnt 29pm blood albumin calcium phos mg 40pm blood albumin cholest 08am blood phos mg 40pm blood hba1c eag 40pm blood triglyc hdl chol hd ldlcalc 29pm blood asa neg ethanol neg acetmnp neg tricycl neg 40pm blood lactate cta head findings ct head without contrast a x cm intra axial hypodense focus is seen in the left cerebellar hemisphere exerting mass effect on the adjacent fourth ventricle without evidence of associated hydrocephalus subtle hyperdensity within the left cerebellar hemisphere lesion suggests possible underlying microhemorrhage the ventricles and sulci are prominent consistent global cerebral volume loss patchy periventricular hypodensities are most consistent with chronic microvascular ischemic disease the left mastoid air cells are underpneumatized with a small effusion the visualized portion of the paranasal sinuses right mastoid air cells andbilateral middle ear cavities are clear the visualized portion of the orbits demonstrates sequela of prior bilateral cataract surgery cta head infundibular origin of the right posterior cerebral artery otherwise the vessels of the circle of and their principal intracranial branches appear normal without stenosis occlusion or aneurysm formation the dural venous sinuses are patent cta neck atherosclerotic changes of the carotid bifurcations are seen without narrowing of the internal carotid arteries by nascet criteria mild atherosclerotic disease narrows the origin of the left common carotid and vertebral arteries the vertebral arteries appear otherwise unremarkable with no evidence of stenosis or occlusion the bilateral subclavian arteries are unremarkable allowing for mild atherosclerotic disease other the visualized portion of the lungs demonstrates an mm nodule in the right upper lobe is seen on the prior chest x ray a smaller mm right upper lobe nodule also noted a multinodular goiter is seen with largest nodule measuring approximately cm on the left there is no lymphadenopathy by ct size criteria impression x cm intra axial hypodense focus in the left cerebellar hemisphere likely represents a late acute to subacute infarct no large hemorrhage identified possible microhemorrhages within the region of infarct allowing for atherosclerotic disease essentially unremarkable cta of the head and neck no evidence of occlusion no stenosis of the cervical internal carotid arteries by nascet criteria mm nodule in the right upper lobe a smaller mm right upper lobe nodule also noted multinodular goiter largest discrete nodule appears to be approximately cm in the left lobe small left mastoid effusion recommendation s for incidentally detected single solid pulmonary nodule measuring to mm a ct follow up in to months is recommended in a low risk patient optionally followed by a ct in months in a high risk patient a ct follow up in to months and a ct in months is recommended see the guidelines for the management of pulmonary nodules incidentally detected on ct for comments and reference thyroid nodule ultrasound follow up recommended college of radiology guidelines recommend further evaluation for incidental thyroid nodules of cm or larger in patients under age or cm in patients age or or with suspicious findings suspicious findings include abnormal lymph nodes those displaying enlargement calcification cystic components and or increased enhancement or invasion of local tissues by the thyroid nodule mri brain impression x x cm left cerebellar hemisphere focus of diffusion and gradient echo susceptibility artifact felt to be most compatible with late acute infarct in hemorrhagic transformation associated linear foci of enhancement predominantly located within the cerebellar folia is felt to be secondary to luxury perfusion rather than nodular enhancement of underlying mass lesion associated edema pattern results in mass effect and mild effacement of the fourth ventricle no definite evidence of hydrocephalus the size of the ventricles are unchanged from outside hospital examination of recommend repeat mri head with without contrast in approximately month to document stability or resolution of linear enhancement to exclude underlying lesion additional findings as described above tte conclusion the left atrial volume index is mildly increased the right atrium is mildly enlarged there is no evidence for an atrial septal defect by 2d color doppler the estimated right atrial pressure is mmhg there is normal left ventricular wall thickness with a normal cavity size there is normal regional and global left ventricular systolic function no thrombus or mass is seen in the left ventricle quantitative 3d volumetric left ventricular ejection fraction is there is a mild peak mmhg resting left ventricular outflow tract gradient no ventricular septal defect is seen tissue doppler suggests an increased left ventricular filling pressure pcwp greater than 18mmhg there is echocardiographic evidence for diastolic dysfunction grade indeterminate normal right ventricular cavity size with normal free wall motion the aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender there is a normal descending aorta diameter there is no evidence for an aortic arch coarctation the aortic valve leaflets are mildly thickened no masses or vegetations are seen on the aortic valve there is no aortic valve stenosis there is no aortic regurgitation the mitral valve leaflets are mildly thickened with no mitral valve prolapse no masses or vegetations are seen on the mitral valve there is trivial mitral regurgitation the tricuspid valve leaflets appear structurally normal no mass vegetation are seen on the tricuspid valve there is mild to moderate tricuspid regurgitation there is mild pulmonary artery systolic hypertension there is no pericardial effusion impression normal left ventricular wall thickness cavity size and regional global systolic function increased pcwp diastolic dysfunction mild to moderate tricuspid regurgitation mild pulmonary artery systolic hypertension mr perfusion findings again seen is cerebellar abnormality on t1 postcontrast images stable since yesterday asl perfusion there is decreased perfusion in the left inferior cerebellar hemisphere corresponding to the left cerebellar hemisphere infarct identified on brain mri day prior mr spectroscopy relatively preserved spectroscopy pattern no evidence of tumor spectra impression findings consistent with left cerebellar infarct brief hospital course ms is a year old right handed female with a h o afib on eliquis tiidm and htn who presents with days of nausea unsteady gait and word finding difficulty and was transferred to from osh after abnormal findings on nchct left intrapernchymal cerebellar lesion the patient complains of nausea and gait disturbance lasting days and the patient s daughter began to notice word finding difficulty and gait disturbance during this same period the patient s daughter also reported that the patient has been declining cognitively and lost approximately pounds over the past several months the patient s family history is notable for two incidences of brain cancer with one confirmed gbm the patient s physical exam did not provide any localizing or alarming findings demonstrating minor ataxia that has improved since admission and the patient is now able to ambulate with assistance initial nchct showed a hypodense focus in the left cerebellar hemisphere and cta did not show any evidence of an occlusion in the head or neck mri w and w o contrast showed a left cerebellar hemisphere lesion with restricted diffusion and gradient echo susceptibility f u mr perfusion scanning demonstrated hypoperfusion in that region and did not show any evidence of tumor spectra this lesion most likely represents a subacute venous infarct with surrounding edema and hemorrhagic transformation given the hypoperfusion on mr spectroscopy and preserved spectroscopy pattern mass unlikely abscess infection is unlikely given lack of elevated wbc or fever constitutional symptoms stroke risk factor labs show hba1c ldl repeat mri weeks after discharge to monitor concerning changes in lesion e g continued bleed change in morphology that could suggest mass hold eliquis for weeks continue asa cognitive decline patient has inattention difficulty with recall will need more thorough mental status memory cognition work up and rehab after discharge afib eliquis held aspirin continued this should be re started after a repeat mri brain is done in about weeks if the hemorrhage is stable improved her atenolol was decreased from 50mg to 5mg daily due to bradycardia diabetes the patient was initially started on steroids decadron when this lesion was thought to be a mass her sugars prior to even starting the steroids however were also elevated and her a1c was elevated at a diabetes consult was placed as her glucose levels were still elevated on a sliding scale insulin regiment and she was discharged on insulin gait unsteadiness due to cerebellar stroke recommended rehab transitional issues follow blood sugars very carefully repeat mri in weeks before starting eliquis follow up with neurology incidental pulmonary and thyroid nodules found on ct follow up with pcp for further imaging 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 other reasons documented by physician advanced practice nurse physician physician apn pa or pharmacist ldl c less than mg dl smoking cessation counseling given yes x no reason x non smoker unable to participate stroke education personal modifiable risk factors how to activate ems for stroke stroke warning signs and symptoms prescribed medications need for followup given verbally or written x yes no assessment for rehabilitation or rehab services considered x yes no if no why not i e patient at baseline functional status discharged on statin therapy yes x no if ldl reason not given statin medication allergy other reasons documented by physician advanced practice nurse physician physician apn pa or pharmacist x 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 x no if no why not i e bleeding risk etc n a bleeding risk due to hemorrhagic conversion of ischemic infarct medications on admission the preadmission medication list is accurate and complete apixaban mg po bid atenolol mg po daily donepezil mg po daily metformin glucophage mg po bid welchol colesevelam gram oral breakfast discharge medications glargine units bedtime humalog units breakfast humalog units lunch humalog units dinner insulin sc sliding scale using reg insulin atenolol mg po daily donepezil mg po daily metformin glucophage mg po bid welchol gram oral breakfast held apixaban mg po bid this medication was held do not restart apixaban until after your doctor says it is okay discharge disposition extended care facility discharge diagnosis acute cerebellar infarct with hemorrhagic conversion discharge condition mental status confused always level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear ms you were admitted to because you were having difficulty walking nausea and some confusion resulting from an acute ischemic stroke a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot the brain is the part of your body that controls and directs all the other parts of your body so damage to the brain from being deprived of its blood supply can result in a variety of symptoms you went to an outside hospital where a cat scan of your brain was done which showed a worrisome lesion you then were transferred to in where we ran two more tests including two mri brain scans we initially thought that the lesion in your brain could have been a mass but on further testing the finding is more consistent with a stroke stroke can have many different causes so we assessed you for medical conditions that might raise your risk of having stroke in order to prevent future strokes we plan to modify those risk factors your risk factors are atrial fibrillation diabetes hyperlipidemia hypertension we are worried that you were not taking your medications because your sugar was also high in your blood therefore we have started you on insulin your heart rate was low and your blood pressure was good while you were in the hospital so we decreased your atenolol from 50mg daily to 5mg daily you worked with physical therapy who recommended rehab to get you better and safe as you had this stroke affecting your balance in two weeks we would like to repeat a scan to ensure that your stroke is improving in the meantime do not re start the eliquis apixaban until the scan is done once the repeat brain scan has been completed your facility should re start the blood thinner at that time thank you for involving us in your care sincerely neurology followup instructions

name unit no admission date discharge date date of birth sex f service neurosurgery allergies sulfa sulfonamide antibiotics attending chief complaint neck pain major surgical or invasive procedure c6 acdf history of present illness presenting with neck pain with mri showing c6c7 disc herniation w o cord compression or myelopathy past medical history chronic back pain s p l4l5 laminectomy discectomy in social history family history mother with back problems and surgeries physical exam opens eyes x spontaneous to voice to noxious orientation x person x place x time follows commands simple x complex none pupils right left eom x full restricted face symmetric x yes notongue midline x yes no pronator drift yes x no speech fluent x yes no comprehension intact x yes no motor throughout wound dressing c d i collar in place pertinent results please see omr brief hospital course ms is a with c6c7 disc herniation who underwent an uncomplicated c6 acdf on by dr the postoperative course was uncomplicated and is summarized by systems below neuro a x ray of the c spine was performed on pod and showed no c6 acdf without acute complications pain was well controlled on an oral regimen a hard collar was given she was continued on her home wellbutrin lexapro and adderall gi diet was advanced as tolerated she had no problems on a bedside swallow exam performed on pod gu she voided postoperatively without complications id perioperative ancef was given heme scds were given for dvt prophylaxis by the time of discharge on pod she was tolerating a regular diet voiding ambulating and with adequate pain control medications on admission bupropion er adderall lexapro medical marijuana discharge medications bupropion er adderall lexapro oxycodone tylenol discharge disposition home discharge diagnosis c6 disc herniation discharge condition stable discharge instructions surgery your dressing may come off on the second day after surgery please keep wearing the hard collar until your follow up appointment 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 you must wear your cervical collar at all times the collar helps with healing and alignment of the fusion you must wear your cervical collar while showering you may remove your collar briefly for skin care be sure not to twist or bend your neck too much while the collar is off it is important to look at your skin and be sure there are no wounds of the skin forming we recommend that you avoid heavy lifting running climbing or other strenuous exercise until your 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 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 obstetrics gynecology allergies nsaids non steroidal anti inflammatory drug attending chief complaint pelvic cramping major surgical or invasive procedure dilation and curettage physical exam discharge physical exam vitals vss gen nad a o x cv rrr resp no acute respiratory distress abd soft appropriately tender no rebound guarding ext no ttp pertinent results labs 15am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 16am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 50pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 25pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt ct 50am 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 16am blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 50pm blood neuts bands lymphs monos eos baso myelos absneut abslymp absmono abseos absbaso 00pm blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 50pm blood hypochr anisocy poiklo normal macrocy normal microcy polychr normal 50pm blood plt smr very low plt ct 15am blood plt ct 16am blood plt ct 25pm blood plt ct 50am blood plt ct 50am blood ptt 00pm blood plt smr low plt ct 00pm blood glucose urean creat na k cl hco3 angap 00pm blood genta 50pm blood lactate 00am blood lactate 00am blood hgb calchct 30pm urine color yellow appear clear sp 35pm urine color yellow appear hazy sp 30pm urine blood mod nitrite neg protein glucose neg ketone bilirub neg urobiln neg ph leuks sm 35pm urine blood neg nitrite neg protein tr glucose neg ketone neg bilirub neg urobiln neg ph leuks sm 30pm urine rbc wbc bacteri few yeast none epi microbiology pm blood culture blood culture routine pending pm urine source final report urine culture final beta streptococcus group b cfu ml pm blood culture source venipuncture blood culture routine pending pm urine final report urine culture final mixed bacterial flora colony types consistent with skin and or genital contamination imaging pelvic ultrasound final report examination early ob us 14weeks indication g2p0 12w p w abdominal pain eval for trimester pregnancy lmp technique transabdominal and transvaginal examinations were performed transvaginal exam was performed for better visualization of the embryo comparison none findings an intrauterine gestational sac is seen and a single living embryo is identified with a crown rump length of mm representing a gestational age of weeks days this corresponds satisfactorily with the menstrual dates of weeks days the uterus is normal the ovaries are normal there is funnel shaped dilation of the cervix measuring mm at its widest point at the internal os impression single live intrauterine pregnancy with size dates cervical dilation measuring up to mm at its widest point at the internal os pelvic ultrasound final report examination pelvis non obstetric indication w sab evaluate for retained placenta most fetal tissue has passed w sab evaluate for retained placenta most fetal tissue has passed technique grayscale ultrasound images of the pelvis were obtained with transabdominal approach followed by transvaginal approach for further delineation of uterine and ovarian anatomy comparison pelvic ultrasound findings the uterus is anteverted previously noted gestational sac and fetus are no longer present the endometrial cavity is distended with heterogeneous echogenic material with vascularized products seen posteriorly at the level of the uterine body measuring at least x cm in transverse compatible with vascularized retained products of conception in addition there is heterogeneous echogenic material without vascularity in the endocervical canal concerning for blood products small amount of free fluid in the pelvis normal ovaries bilaterally impression findings consistent with vascularized retained products of conception measuring at least x cm in transverse with additional echogenic blood products in the endocervical canal small amount of free fluid brief hospital course ms is a yo g3p0 who presented to the ed at 12weeks gestational age with cramping she underwent a pelvic ultrasound on which demonstrated a live single intrauterine pregnancy while in the ed she developed worsening cramping and vaginal bleeding and she passed fetal tissue repeat pelvic ultrasound revealed retained products of conception in the ed pt was noted to be tachycardic hr max with tmax her labs were notable for increasing leukocytosis thought to be secondary to an inflammatory reaction to her miscarriage differential included uterine infection i e endometritis the decision was made to proceed with a dilation and curettage for complete removal of pregnancy tissue on ms underwent an uncomplicated ultrasound guided dilation and curettage please refer to the operative note for full details she had an estimated blood loss of 350ml and received methergine and cytotec intraoperatively she was continued on po methergine for hours post operatively she also received iv doxycycline intra operatively due to concern for developing endometritis her hematocrit was trended pre operative pacu post operative day post operative day am her post operative course was complicated by fever and thrombocytopenia fever pt spiked a fever to on post operative day her cbc at the time was notable for wbc with bands ua was negative for uti she was treated for presumed endometritis and received iv gentamicin and iv clindamycin for hours she was then transitioned to po doxycycline and po flagyl thrombocytopenia pt was noted to have downtrending platelets with nadir of thought due to itp vs gestational thrombocytopenia her vaginal bleeding was minimal following the procedure and her platelet count improved prior to discharge platelet on nsaids were held during this admission in the setting of thrombocytopenia thee remainder of her post operative course was uncomplicated she received po tylenol and oxycodone prn pelvic pain her diet was advanced without difficulty she voided spontaneously on post operative day by hospital day pt was tolerating a regular diet voiding spontaneously ambulating independently and her pain was well controlled with oral medications she was discharged to home with outpatient follow up scheduled discharge medications acetaminophen mg po q6h prn pain mild reason for prn duplicate override patient is npo or unable to tolerate po do not exceed 4000mg in hours rx acetaminophen mg tablet s by mouth every hours disp tablet refills docusate sodium mg po bid prn constipation rx docusate sodium mg tablet s by mouth twice daily disp tablet refills doxycycline hyclate mg po q12h duration days rx doxycycline hyclate mg tablet s by mouth twice daily disp tablet refills ferrous sulfate mg po daily rx ferrous sulfate mg mg iron tablet s by mouth daily disp tablet refills metronidazole mg po tid rx metronidazole flagyl mg tablet s by mouth twice daily disp tablet refills discharge disposition home discharge diagnosis retained products of conception discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms you were admitted to the gynecology service after your procedure you have recovered well and the team believes you are ready to be discharged home please call dr office with any questions or concerns please follow the instructions below general instructions take your medications as prescribed do not take more than 4000mg acetaminophen apap in hrs please avoid nsaids ex ibuprofen in the setting of your low platelet counts do not drive while taking narcotics take a stool softener such as colace while taking narcotics to prevent constipation do not combine narcotic and sedative medications or alcohol no strenuous activity until your post op appointment nothing in the vagina no tampons no douching no sex until your post operative appointment no heavy lifting of objects lbs for weeks you may eat a regular diet you may walk up and down stairs 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 you are unable to keep down fluids food or your medication to reach medical records to get the records from this hospitalization sent to your doctor at home call followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies demerol morphine attending chief complaint generalized weakness muscle aches intermittent fevers sore throat and wakes up with ha now with bcx major surgical or invasive procedure tee picc line insertion history of present illness patient is a m with pmh hld duodenal ulcer c b gib and bph who presents with chills ha and positive blood cultures weeks ago developed waxing and waning generalized muscle aches with subjective chills but no objective fever bifrontal mild headache without other associated neurological signs no recent travel other than and upstate no history of ivdu he had a dental cleaning weeks ago after the onset of symptoms he did have a colonoscopy days prior to developing symptoms per referral pt has gram positive cocci growing out of each anaerobic blood culture two sets were drawn after hours he presented with weeks of headache fatigue and myalgias esr has dropped his hct to yesterday from on i consulted with id who recommended ed eval and likely admit for repeat cx r o endocarditis and imaging of head given headache and concern for mycotic aneurysm and abdomen to look for a source he did have a colonoscopy with polypectomy on he had dental cleaning after the onset of his sx in the ed initial vs were ra exam notable for exam normal neuro rectal heme negative soft systolic murmur in rusb labs showed hgb imaging showed cxr no acute cardiopulmonary process head ct no acute intracranial process received vanc cefazolin transfer vs were ra on arrival to the floor patient reports that he has been having myalgias and ha x weeks on and off he endorses slight fever his ha is mild dull all over and occurs in the mornings but does not wake him up no associated photophobia phonophobia neck stiffness blurry vision dizziness or nausea tylenol helps he also endorses various wandering muscle pains but no joint pains he was tested for lyme but it was negative and he denies tick exposure he did have a colonoscopy around the time his sx started but denies abdominal pain constipation or diarrhea he denies chest pain or dizziness he denies trauma or sick contacts review of systems per hpi past medical history hypercholesterolemia rhinitis allergic duodenal ulcer with hemorrhage dermatitis seborrheic serrated adenoma of colon sleep disturbance bph benign prostatic hyperplasia cholecystectomy social history family history mother with father with hairy cell leukemia stroke mi in maternal uncle and mgm physical exam admission physical exam vs po ra general pleasant alert nad appears younger than stated age heent at nc eomi perrl anicteric sclera pink conjunctiva mmm oropharynx clear neck supple intact chin to chest 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 ruq scar 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 vs 4po r ra general pleasant alert nad appears younger than stated age heent at nc eomi perrl anicteric sclera pink conjunctiva mmm oropharynx clear neck supple no lad heart rrr s1 s2 no murmurs gallops or rubs lungs ctab no wheezes rales rhonchi breathing comfortably without use of accessory muscles abdomen nondistended nontender in all quadrants no rebound guarding ruq scar 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 pertinent results admission labs 01pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 01pm blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 01pm blood glucose urean creat na k cl hco3 angap 19pm blood lactate microbiology pm blood culture final report blood culture routine final streptococcus anginosus milleri group final sensitivities sensitivities mic expressed in mcg ml streptococcus anginosus group ceftriaxone s clindamycin s erythromycin s penicillin g s vancomycin s aerobic bottle gram stain final gram positive cocci in chains reported to and read back by on patient credited anaerobic bottle gram stain final gram positive cocci in chains pm blood culture final report blood culture routine final streptococcus anginosus group identification and sensitivities performed on culture aerobic bottle gram stain final gram positive cocci in chains reported to and read back by on anaerobic bottle gram stain final gram positive cocci in pairs and chains blood culture routine final no growth pertinent imaging ct head w o contrast no acute intracranial process tte mildly thickened aortic valve with moderate aortic regurgitation myxomatous mitral leaflets with mild moderate late systolic mitral regurgitation normal biventricular cavity sizes with preserved regional and global biventricular systolic function if clinically indicated a transesophageal echocardiographic examination is recommended to better assess the aortic and mitral valve morpholgy for possible vegetations endocarditis tee mildly thiickened aortic valve leaflets with moderate aortic regurgitation but without discrete vegetation mild bileaflet mitral valve prolapse with mild late systolic mitral regurgitation discharge labs 20am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 02pm blood crp brief hospital course patient is a m with pmh hld duodenal ulcer c b gib and bph who presented with chills myalgias and headache admitted with viridans strep sepsis viridans strep sepsis initial cultures at grew gpcs that resulted in viridans strep species initial blood cultures on admission to were also positive for viridians strep all culture sensitivities were pan sensitive see microbiology section for specific sensitivity data the patient was started on vancomycin empirically and ultimately narrowed to ceftriaxone based on culture sensitivities etiology of gpc sepsis was unclear tte was negative for vegetations but showed bileaflet mitrial prolapse and aortic regurgitation a tee was performed that was negative for vegetations there were no localizing symptoms dentition was good though patient had previous dental instrumentation prior to admission a panorex was performed and the result will be followed up after discharge a picc was placed prior to discharge the patient will continue ctx as an outpatient for a total course of weeks d1 projected end date normocytic anemia hgb during admission was previous baseline in was no evidence of bleeding hgb remained stable workup with iron studies if anemia does not resolve after acute illness headache patient was experiencing intermittent headaches on admission that were relieved with tylenol he did not experience nausea photo phonophobia blurry vision or any worrisome signs or symptoms a ct head was negative he was continued on tylenol prn during hospitalization chronic hld continued home atorvastatin bph continued home tamsulosin seasonal allergies continued flonase claritin transitional issues new medications ceftriaxone 2mg iv daily for a total course of weeks d1 projected end date items for follow up follow up final panorex read date of exam lab draw every week cbc with differential bun cr ast alt total bili alk phos crp esr infectious disease opat will arrange outpatient follow up continue ctx as an outpatient for a total course of weeks d1 projected end date or instructed by infectious disease follow up weekly cbc if hgb trending down hgb at discharge send for iron studies and work up patient has had a gi bleed in the past echo showed bileaflet mitrial valve prolapse and mild aortic regurgitation please continue to monitor patient and consider referral to cardiology for surveillance name of health care proxy relationship wife phone number code full code medications on admission the preadmission medication list is accurate and complete trazodone mg po qhs prn insomnia tamsulosin mg po qhs atorvastatin mg po qpm loratadine mg po daily fluticasone propionate nasal spry nu daily epipen epinephrine mg ml injection asdir discharge medications ceftriaxone gm iv q 24h rx ceftriaxone in dextrose iso os gram ml mg iv q24h disp intravenous bag refills atorvastatin mg po qpm epipen epinephrine mg ml injection asdir fluticasone propionate nasal spry nu daily loratadine mg po daily tamsulosin mg po qhs trazodone mg po qhs prn insomnia discharge disposition home with service facility discharge diagnosis primary diagnosis sepsis gram positive headache anemia 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 you were admitted to the hospital because you had bacteria in your blood you were given antibiotics through your vein you were seen by the infection doctors who recommended through your vein for four weeks we do not know what caused the infection we looked at your heart valves with an ultrasound and did not find an infection hiding in your heart we did a scan of your brain because of your headaches and the scan was normal finally we took xrays of your mouth the results of the mouth xray are pending and you will go over these results when you follow up with your regular doctors someone from the infectious disease department will call you to schedule a follow up appointment if you don t hear from them in a week you can call at it was a pleasure caring for you sincerely your medical team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies no known allergies adverse drug reactions attending chief complaint paranoia major surgical or invasive procedure none history of present illness hpi ms is a year old female with prior history of bipolar disorder psychosis now presenting with acute agitation patient with potentially prior late diagnosis of bipolar disorder psychosis was previously living in for the past year and returned to because of mental status changes weeks prior husband reports that she had become depressed secondary to potentially stress she was also drinking alcohol and she was being self medicated with lorazepam and haldol which she had been previously described before she now is a basket case and feels more paranoid and has potentially lost perception with reality patient thinks that everyone is against her her husband notes that she can be somewhat aggressive sometimes she does endorse emptiness in her head and her husband believes that she may have suffered several strokes in the past as well she does not have any headaches numbness tingling focal neurological deficits or loss of function patient was first evaluated and found to have potentially an exacerbation of bipolar disorder vs alcohol use vs organic neurologic process patient was then evaluated to potentially need geriatric psych management past psychiatry history reviewed in omr patient was initially diagnosed with a bipolar disorder and had a psychotic break a few years ago at that time she was treated with haldol and ativan and had somewhat improvement patient was then potentially tailored off medications and then went into a manic phase that lasted about a year patient was very energetic previously and then mood stable she was also drinking alcohol at that time last year she and her husband then moved to for financial reasons and returned to the because of mental status changes in the ed initial vitals ra labs were significant for sodium potassium bun cr serum tox pending tsh vitamin b12 pending hgb ct head imaging without contrast showed no acute intracranial abnormality in the ed she received po lorazepam mg vitals prior to transfer ua ra currently patient is standing in the room refusing all care patient states that she would like to leave the hospital patient states that she feels that she is being kept here against her will ros unable to assess patient is not able to assess past medical history bipolar disorder psychotic break social history family history declines answering questions physical exam admission physical exam gen patient is refusing to acknowledge name date of birth or place she continues to state that she does not need to be here patient also continues to state that she would like to leave heent anicteric scleare no conjunctival pallor patient refusing mouth examination cv rrr s1 s2 lungs refusing exam abd refusing exam extrem warm well perfused no edema neuro cn ii xii grossly intact extremities grossly intact she was able to walk to the restroom by herself without help gait appears normal discharge physical exam gen patient repeats name year declines answering more questions heent anicteric scleare no conjunctival pallor cv rrr s1 s2 lungs refusing exam abd refusing exam extrem warm well perfused no edema neuro cn ii xii grossly intact extremities grossly intact she was able to walk to the restroom by herself without help gait appears normal pertinent results pertinent labs 03am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 03am blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 03am blood glucose urean creat na k cl hco3 angap 03am blood vitb12 03am blood tsh 03am blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg pertinent reports imaging ct head w o contrast there is no intra axial or extra axial hemorrhage edema shift of normally midline structures or evidence of acute major vascular territorial infarction ventricles and sulci are normal in overall size and configuration there is a mucus retention cyst in the left maxillary sinus with thickening of the lateral wall of the left maxilla suggesting chronic inflammation the remaining imaged paranasal sinuses are clear mastoid air cells and middle ear cavities are well aerated the bony calvarium is intact impression no acute intracranial process imaging mr head w w o contras study is mildly degraded by motion there is no evidence of hemorrhage edema masses mass effect midline shift or infarction there is prominence of the ventricles and sulci suggestive involutional changes few subcortical t2 and flair hyperintensities are noted there is no abnormal enhancement after contrast administration the major vascular flow voids are preserved there is partial opacification of the mastoid air cells mucosal thickening with an air fluid levels noted in the left maxillary sinus mild mucosal thickening of the ethmoid sinuses seen there is a cm tornwaldt cyst versus mucous retention cyst in the posterior nasopharynx the orbits and visualized soft tissues are otherwise normal nonspecific bilateral mastoid fluid is present degenerative changes are noted in the upper cervical spine impression study is mildly degraded by motion no acute intracranial abnormality few scattered white matter signal abnormalities likely secondary to chronic microvascular ischemic changes air fluid level in the left maxillary sinus which may represent acute sinusitis brief hospital course ms is a year old female with past history of bipolar disorder psychosis now presenting with acute on chronic paranoia active issues paranoia patient initially presented to given increased paranoia and inability to care for herself she was brought in by her husband and history obtained by both patient and collateral from her husband patient had previously been diagnosed with a bipolar disorder syndrome and then patient moved to year ago over the past several months patient had worsening paranoia and agitation and therefore presented to patient had initial blood work which was unrevealing for an organic cause of her symptoms and evaluated by psychiatry psychiatry felt that much of her symptoms were likely secondary to a depression with psychotic features type diagnosis instead of worsening of a prior diagnosis of bipolar patient was initially started on treatment with zyprexa mg qhs and ativan given prior history of this she was monitored serially and underwent ct head and mri imaging which was also negative for an acute organic cause of her symptoms therefore patient was medically clear patient was started on empiric therapy for depression with mirtazapine and was continued on standing anti psychotic patient was also placed under on given inability to make full healthcare decisions patient was started on thiamine given nutritional needs elevated sbp patient was noted to have an elevated sbp on admission however this resolved during serial vital signs as an inpatient and therefore likely secondary to stress than true hypertension transitional issues paranoia patient to have f u with geriatric psych unit patient may benefit from further behavioral stabilization potentially ect and then will require further formal neurologic workup when behavirorally stable discharge psychiatric regimen patient was started on mirtazapine mg qhs and also zyprexa 5mg qhs social situation patient and her husband recently moved back from likely need follow up regarding resources code status full contact husband medications on admission none discharge medications mirtazapine mg po qhs olanzapine disintegrating tablet mg po qhs thiamine mg po daily discharge disposition extended care facility discharge diagnosis primary diagnosis paranoia 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 hospital stay at you were hospitalized here because of an acute paranoia and change in mood and we did blood tests and head imaging with a ct scan and an mri which were negative therefore we believe that you will benefit from psychiatric treatment please follow up with you physicians upon discharge from the hospital take care your team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies allopurinol and derivatives penicillins ace inhibitors attending chief complaint cough major surgical or invasive procedure none history of present illness ms is a yo woman with past history of esrd s p transplant now on dialysis anuric last received dialsis on copd on 3l home o2 atrial fibrillation not on anticoagulation she presented with days of shortness of breath and back pain which has been worsening she was in her normal state of health at her dialysis on on she endorsed a productive cough no sick contacts fevers but subjective chills and some back pain which she initially described as a constant burning throughout her whole back this sensation has now resolved denies cp worsening orthopnea in the ed initial vitals nasal cannula she had one rectal temp of early on the morning of admission exam notable for diffuse crackles on pulmonary examination labs were notable for wbc hgb hct platelet inr serum asa serum apap lactate imaging showed negative cta for pe multiple intrathoracic lymph nodes bedside u s showed no pericardial effusion patient was given pr acetaminophen mg ih albuterol neb soln neb ih ipratropium bromide neb neb iv vancomycin mg ivf ml ns ml iv insulin regular units iv dextrose gm iv calcium gluconate gm iv levofloxacin mg po metoprolol succinate xl mg consults renal recommended possible crrt vs ihd today depending on blood pressure stability recommended empiric treatment for hcap on arrival to the micu she confirmed the above story stating that her burning back pain has now dissipated she denies any increased shortness of breath she endorses continued diarrhea daily but denies any abdominal pain past medical history past medical history esrd s p transplant in fsgs by biopsy on hd s p dcdkd in c b chronic allograft nephropathy in with reinitiation of hd on mwf schedule complicated by intradialytic hypotension atrial fibrillation not on anticoagulation due to significant gastrointestinal as well as av fistula site bleeding bradycardia copd on home oxygen fev1 of predicted diastolic chf last tte in with ef symmetric lvh dilated rv with borderline systolic function and severe pulmonary htn small septum secundum claudication with concern for peripheral vascular disease no formal arterial duplex studies on record gerd gout hsv ii htn pulmonary htn no prior documentation but likely group tobacco abuse anemia gi bleed recurrent c diff colitis initially diagnosed in and treated with flagyl 500mg x days again in s p flagyl 500mg x days persistent infection still later in treated with vanco 125mg po x14days h o syphilis h o breast cysts past surgical history open cholecystectomy tubal ligation with incision from midline to pubis exploratory laparotomy for ovarian cyst negative social history family history mother was on dialysis from dm niece has esrd s p transplant physical exam admission physical exam vitals t bp p sp02 on ra general lethargic but arousable falling asleep intermittently heent sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs on ra mild increase work of breathing fair air exchange crackles and wheezes in lower to mid lung fields cv irregularly irregular rhythm normal s1 s2 no murmurs rubs gallops abd soft non tender slightly distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused pulses mild edema to ankles neuro cn ii xii grossly intact moving all extremities appropriately access lue fistula pivs discharge physical exam vs ra i o 3l during hd gen well nourished appearing dark skinned woman sitting up in bed in nad heent nt at white hair disconjugate gaze mild scleral icterus eomi both eyes track but right eye unable to pass midline this is her baseline perrla mmm moist but tongue coated in thick white yellow plaques improved compared to prior day neck supple symmetric no ac pc or supraclavicular chain lad jvp difficult to assess i s o afib but external jugular vein very prominent on exam today cv variable s1 s2 regular rate no m r g pulm breathing comfortably on nc with slightly increased rate and mildly increased wob good air movement throughout posteriorly bronchial breath sounds in b l bases no frank wheezes rhonchi or crackles abd soft mildly distended non rigid mildly tender to palpation diffusely worst in the epigastrium no r g bs ext warm well perfused no pitting edema in ble dp palpable b l skin no appreciable rashes hyperpigmented scar in ruq from prior cholecystectomy hypopigmented skin over recently accessed lue avf neuro alert interactive on exam no gross deficits appreciated access piv lue avf with palpable thrill pertinent results admission labs 50am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 50am blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 50am blood ptt 50am blood glucose urean creat na k cl hco3 angap 50am blood alt ast alkphos totbili 50am blood lipase 50am blood ctropnt 50am blood albumin calcium phos mg 50am blood asa ethanol neg acetmnp bnzodzp neg barbitr neg tricycl neg 59am blood lactate other important labs none microbiology influenza a positive influenza b negative blood culture x2 ngtd pending blood culture x2 ngtd pending hiv serologies negative h pylori serologies pending at time of discharge imaging and other studies cta chest mild pulmonary edema cardiomegaly moderate with biatrial chamber enlargement innumerable mediastinal lymph nodes mildly enlarged indeterminate difficult to exclude lymphoma or other etiologies clinical correlation is advised no pulmonary embolism or acute aortic dissection partially visualized abdominal ascites portable cxr bilateral airspace opacities with a central predominance likely reflect pulmonary vascular congestion and mild pulmonary edema difficult to exclude superimposed infection in the appropriate clinical setting ruq ultrasound enlarged liver along with a dilated ivc and hepatic veins is concerning for underlying fluid overload this may also be seen in right heart failure slightly heterogeneous and coarsened liver echotexture no focal lesions no intrahepatic biliary ductal dilation trace ascites discharge labs 30am 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 alt ast ld ldh alkphos totbili 16am blood calcium phos mg brief hospital course ms is a y o woman with past history of esrd s p transplant on hd copd and recurrent c diff infection presenting with volume overload and influenza she had a brief ficu stay for urgent hd was transferred to the floor with improving respiratory and volume status and monitored closely for downtrending hgb and reported melena prior to discharge home active issues hypoxia of multifactorial etiology the patient presented with hypoxia likely due to combination of fluid overload in setting of known chf esrd copd and active influenza a infection her active afib with intermittent rvr was likely further worsening her respiratory status with management of these individual problems as detailed below her respiratory status improved and she was discharged on her home o2 requirement of by nc influenza a infection the patient was found to be flua positive per pcr on admission and started on tamiflu for ue to hd dosing she did have infectious work up for potential superinfection with pna but chest imaging was without notable findings she was briefly on empiric abx and had blood cultures drawn with no growth at time of discharge anemia of unclear etiology at baseline the patient had a hemoglobin of likely due to esrd the patient did not appear malnourished on exam but of note nutritional studies had not been performed in several years as detailed below there was concern for underlying liver disease in this patient which could have been contributing to her overall anemia additionally active influenza infection could possibly have caused transient myelosuppression during this admission the patient further endorsed black stool new for several days prior to and during this admission and was found to be guaiac positive in the ficu with trending her hemoglobin did downtrend from her baseline to at time of transfer to the general medicine service concerning for upper gi bleed especially given her prior history of bleeding she was briefly put on iv ppi and had h pylori serologies sent the patient was found still to be guaiac positive but without melena on rectal exam and her hemoglobin did return to her baseline prior to discharge the patient was arranged for outpatient follow up with gi for further evaluation of possible gi bleed she was also instructed to follow up with her outpatient providers regarding results of her h pylori serologies anuric end stage renal disease s p dcdrt complicated by allograft failure re initiated on hd the patient has had a history of esrd since initially on hd she underwent dcdrt in with subsequent allograft failure and re initiation on hd in she has an estimated dry weight of 66kg and was continued on her home hd schedule she was also continued on her home calcium supplements and phosphorus binders she was followed closely by the renal hd service during this admission and discharged home following her last dialysis session on at her dry weight of 2kg recurrent c diff colitis the patient has failed multiple courses of treatment for c diff colitis and was treated for another episode of recurrent c diff during this admission she was initiated on vancomycin 125mg po q6h and flagyl 500mg iv q8h on while in the icu and continued on a planned day course of po vancomycin she was discharged home with enough vancomycin capsules to complete her days course last dose on she should also follow up with her pcp and gi about potentially pursuing stool transplant given her multiple relapses atrial fibrillation the patient has had a history of poorly controlled afib due to inability to effectively rate control in the setting of intradialytic hypotension she was rate controlled with fractionated metoprolol equivalent in dosage to her home metoprolol xl 25mg po daily during this admission she was continued on asa 81mg po daily for stroke prophylaxis during this admission as she has been unable to tolerate systmic anticoagulation in the setting of active and prior gi bleeding as well as prior av fistula site bleeding despite a chads2vasc of diastolic congestive heart failure complicated by right heart failure the patient has moderate diastolic dysfunction with preserved ef per last tte in s elevated right heart pressures as well as rv systolic dysfunction seen on tte as well as right heart cath her chf was felt to be a major contributor to her overall volume overload which improved with treatment of her influenza and dialysis copd on home o2 the patient has pfts from c w restrictive lung disease but prior pfts showing obstructive disease she was continued on her home inhaler regimen with added duonebs prn and discharged on her home oxygen regimen of per nc mediastinal lymphadenopathy the patient was noted to have mediastinal lad on chest imaging likely reactive due to influenza however there was concern given poor follow that this could be due to an alternate etiology such as lymphoma or perhaps sarcoidosis initial work up in the hospital was unrevealing with normal ldh and negative ace levels her hydroxy vitamin d levels to evaluate for sarcoidosis were still pending at time of discharge she was instructed to follow up with her pcp regarding results of this test and she should had repeat chest ct to re evaluate for finding of mediastinal lymphadenopathy thrush the patient was found to have thrush on exam during this admission likely due to underlying esrd as well as use of oral steroid inhalers she was provided nystatin swish and spit with improvement in her thrush she also had hiv serologies re sent which were still pending at time of discharge she should follow up with her pcp regarding results of this test hypertension the patient has history a history of hypertension with blood pressures largely within normal limits during this admission she did have low blood pressures likely triggered by dialysis she responded well to gentle intravenous fluid boluses in the setting of her tenuous respiratory status she was continued on her fractionated metoprolol and her fluid status was managed with hd as above her blood pressures were normal at time of discharge chronic stable resolved issues concern for underlying liver disease the patient was admitted with elevated transaminases and inr as well as history of concern for underlying liver disease she had ct in showing nodular liver disease and perihepatic ascites prior hep a b c studies negative with hep a c negative as recently as the patient had ruqus this admission showing signs of congestive hepatopathy suggesting acute contribution from her volume overload however cirrhosis could not be ruled out her transaminases were monitored closely during this admission and she was treated for her chf and esrd as above with these measures her liver function tests downtrended prior to admission she should have further work up for possible cirrhosis as an outpatient gerd the patient was admitted on oral ppi therapy which was briefly changed to iv ppi due to concern over active gi bleeding as above her h h stabilized and she was resumed on her home omeprazole prior to discharge breast cysts the patient has a history of breast cysts and was continued on her home topical clindamycin throughout this admission transitional issues the patient had point hemoglobin drop with self reported melena and guaiac positive stool as her blood counts stabilized prior to discharge she did not receive further work up as an inpatient she should follow up with gi after discharge for further evaluation the patient should have repeat cbc drawn on with results faxed to dr pcp fax number as part of work up for gi bleed the patient had h pylori serologies sent during this admission results were still pending at time of discharge and the patient should follow up on these with her pcp the patient was discharged with instructions to complete day course of vancomycin 125mg po q6h for her recurrent c diff colitis first dose on last dose on given the patient s recurrent c diff colitis the patient should be arranged for stool transplant evaluation the patient should follow up with dr pulmonology for management of her pulmonary hypertension the patient received hemodialysis per her home schedule of her last hd session was on on discharge the patient s dry weight was 2kg the patient should follow up with her outpatient nephrologist regarding further management of her esrd given her history of hypotension during dialysis would consider potentially starting patient on midodrine or other form of blood pressure support on dialysis days during this admission the patient had elevated lfts and mild markers of synthetic liver dysfunction he had ruq ultrasound showing likely congestive hepatopathy but cirrhosis was not ruled out she should have further work up for cirrhosis as an outpatient the patient was found to have incidental finding of mediastinal lymphadenopathy on cta of the chest this admission this should be followed up with repeat ct as an outpatient inpatient work up for possible sarcoidosis was initiated with oh vitamin d levels pending at time of discharge this should be followed up with her pcp pulmonologist the patient was discharged on her home o2 requirement of liters per nasal cannula patient was discharged home on po nystatin for thrush likely due to inhaled corticosteroid use the patient has endorsed leg pain both prior to and during this admission concerning for possible peripheral vascular disease she should have formal abi s to evaluate as an outpatient code status full code dry weight 2kg medications on admission the preadmission medication list may be inaccurate and requires futher investigation albuterol sulfate mcg actuation inhalation q6h nephrocaps cap po daily calcium acetate mg po daily cinacalcet mg po daily clindamycin solution appl tp daily fluticasone salmeterol diskus inh ih bid lidocaine prilocaine appl tp 3x week metoprolol succinate xl mg po daily pantoprazole mg po q24h aspirin mg po daily discharge medications vancomycin oral liquid mg po q6h will need total day course first day last day rx vancomycin mg capsule s by mouth every hours disp capsule refills clindamycin solution appl tp daily fluticasone salmeterol diskus inh ih bid lidocaine prilocaine appl tp 3x week nephrocaps cap po daily nystatin oral suspension ml po qid rx nystatin unit ml ml by mouth four times a day refills albuterol sulfate mcg actuation inhalation q6h aspirin mg po daily metoprolol succinate xl mg po daily outpatient lab work please draw repeat cbc on and have results faxed to dr at diagnosis anemia icd10 d64 calcium acetate mg po tid w meals omeprazole mg po daily terconazole vaginal qhs prn vaginitis discharge disposition home discharge diagnosis primary diagnosis es hypoxia due to influenza a infection recurrent clostridium difficile colitis anemia of unclear etiology thrombocytopenia of unclear etiology end stage renal disease on hemodialysis diastolic congestive heart failure with right heart failure mediastinal lymphadenopathy without clear etiology thrush congestive hepatopathy secondary diagnosis es atrial fibrillation chronic obstructive pulmonary disease on home oxygen history of kidney transplant with allograft nephropathy failure gastroesophageal reflux disease hypertension history of breast cysts discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms you were admitted to because you were having trouble breathing and were noted to have low blood pressures you were initially cared for in the intensive care unit icu because your potassium levels were high and needed urgent dialysis in the icu you received sessions of dialysis which helped your breathing as you were found to have the flu you were treated with a medication called tamiflu you were also started on an antibiotic to treat your c diff infection upon transferring to the general medicine service you were found to have slowly decreasing blood counts as you were having black stools there was significant concern for an intestinal bleed with close monitoring your blood counts stabilized and you were sent home with instructions to follow up with the gastroenterologists as an outpatient prior to discharge you received more dialysis session and were breathing more comfortably you had also completed treatment for the flu it is important that you continue to take your medications and follow up with your outpatient doctors detailed in the rest of your discharge paperwork it is also very important that you weigh yourself every morning and call your primary care physician if your weight changes by more than lbs thank you for allowing us to be a part of your care your team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies allopurinol and derivatives penicillins ace inhibitors attending chief complaint upper gi bleed major surgical or invasive procedure upper gi endoscopy history of present illness ms is a y o woman with past history of esrd s p transplant on hd copd gerd w out pud atrial fibrillation not on coumadin recurrent cdiff infection presents with hypotension and worsening anemia in setting of melena patient reports dark painless stools for approximately one week underwent hd on morning of admission and was noted to have hb down from baseline and hypotensive to sbp s baseline sbp in s post dialysis she denies fevers chills chest pain sob abdominal pain nausea vomiting dysuria frequency diarrhea of note patient previously trialed on anticoagulation for atrial fibrillation but experienced massive gib without source being identified underwent endoscopy capsule in the ed initial vitals t p bp rr o2 ra exam notable for rectal exam with melena labs were notable for hb b l lactate trop phos remainder electrolytes wnl serum tox negative imaging cxr showed moderate pulmonary edema patient was given iv pantoprazole 80mg iv 1u prbc s consults gi admitted to micu given hypotension and multiple comorbidities on arrival to the micu she reports feeling well and at her baseline she says she would otherwise be driving to the store to grocery shop she does note some dark brown stools but denies seeing frank black stools she denies dizziness lightheadedness chest pain or sob that is worse than baseline she wear 2l of home o2 she has not had any medication changes preceding this admission she denies confusion at home falls or vomiting past medical history past medical history esrd s p transplant in fsgs by biopsy on hd s p dcdkd in c b chronic allograft nephropathy in with reinitiation of hd on mwf schedule complicated by intradialytic hypotension atrial fibrillation not on anticoagulation due to significant gastrointestinal as well as av fistula site bleeding bradycardia copd on home oxygen fev1 of predicted diastolic chf last tte in with ef symmetric lvh dilated rv with borderline systolic function and severe pulmonary htn small septum secundum claudication with concern for peripheral vascular disease no formal arterial duplex studies on record gerd gout hsv ii htn pulmonary htn no prior documentation but likely group tobacco abuse anemia gi bleed recurrent c diff colitis initially diagnosed in and treated with flagyl 500mg x days again in s p flagyl 500mg x days persistent infection still later in treated with vanco 125mg po x14days h o syphilis h o breast cysts past surgical history open cholecystectomy tubal ligation with incision from midline to pubis exploratory laparotomy for ovarian cyst negative social history family history mother on dialysis from dm niece with esrd s p transplant physical exam admission exam vitals hr79 o2 on 2l heent sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs mild inspiratory and expiratory wheezes throughout cv irregularly irregular rhythm normal s1 s2 no murmurs rubs gallops abd distended ttp throughout her stomach bowel sounds present enlarged liver ext warm well perfused pulses trace neuro cn ii xii grossly intact moving all extremities appropriately no asterxsis access lue fistula pivs discharge exam vitals t hr bp rr spo2 on 3l nc general sitting up in bed moving about room heent ncat wears wig r eye exotropia r eye sclera anicteric mmm neck supple no lad lungs breathing comfortably on 3l nc no signs of accessory muscle use ctab moving air throughout mild crackles at l lung base no wheezes rales rhonchi cv rrr normal s1 s2 no m r g abdomen slightly taut in upper abdomen moderately distended without fluid wave liver edge 5cm below r costal margin non tender to percussion and deep palpation no rebound tenderness or guarding scar along r costal margin from prior open cholescytectomy ext wwp pulses no clubbing cyanosis or peripheral edema skin xerosis on bilateral shins neuro a ox3 motor function grossly normal pertinent results admission labs 35am blood hgb 30pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30pm blood neuts monos eos baso nrbc im absneut abslymp absmono abseos absbaso 30pm blood ptt 30pm blood plt 30pm blood glucose urean creat na k cl hco3 angap 30pm blood alt ast ld alkphos totbili 30pm blood ctropnt 30pm blood albumin calcium phos mg 30pm blood afp 30pm blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg 53pm blood lactate interval labs 49am blood ret aut abs ret discharge labs 46am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 46am blood plt 46am blood ptt 46am blood glucose urean creat na k cl hco3 angap 46am blood calcium phos mg microbiology blood cultures pending imaging cxr findings overlying ekg leads are present there is persistent mild cardiomegaly hilar congestion and moderate pulmonary edema is noted linear densities in the mid to lower lungs likely represent platelike atelectasis tiny effusions are likely present no pneumothorax bony structures are intact impression moderate pulmonary edema ruq us impression enlarged liver dilated ivc and hepatic veins are similar to before with a pulsatile waveform in the portal vein findings are consistent with right heart failure heterogeneous echotexture of the liver is similar to before portal vein is patent trace ascites upper gi endoscopy findings esophagus normal esophagus stomach mucosa erythema and erosions of the mucosa were noted in the antrum these findings are compatible with erosive gastritis cold forceps biopsies were performed for histology at the antrum excavated lesions linear ulcerations were seen in the cardia without associated significant hiatal hernia cold forceps biopsies were performed for histology at the cardia duodenum normal duodenum impression gastric ulcer biopsy erythema and erosions in the antrum compatible with erosive gastritis biopsy otherwise normal egd to third part of the duodenum recommendations bid ppi until follow up endoscopy follow up biopsies repeat egd in weeks to follow up ulcerations in cardia would also recommend colonoscopy at the same time given prior colonoscopy prep was fair and a polyp was not removed at the time of her last colonoscopy brief hospital course ms is a y o woman with anuric esrd s p renal transplant c b allograft failure requiring hd atrial fibrillation not on anticoagulation given significant gi and avf site bleeding inr diastolic chf ef in htn copd fev1 fvc in on home o2 pulmonary htn gerd and recurrent c diff colitis admitted for post dialysis hypotension and acute on chronic anemia in the setting of melenotic stools x week active issues upper gi bleed patient with one week of melena acute drop in hb consistent with likely upper gi bleed history of gerd but no pud she does note some abd pain on exam her abd is distended which she says always happens along with pain after eating ice patient had one prior gib in setting of anticoagulation for a fib but source never identified gi consulted in ed she had an egd in which was normal imaging around the time of egd was not suggestive of cirrhosis however in years since that egd she has developed an enlarged and coarsened liver gi consulted in ed no indication for intervention patient treated with bid iv pantoprazole and had no further episodes of melena she was discharged with plan for outpatient gi follow up and potential endoscopy acute on chronic anemia patient initially presented with hgb down from her baseline of her acute on chronic anemia was thought to be due to blood loss given melena x week with contribution from known esrd her hgb increased to after transfusion of 1u prbc and remained stable hypotension patient initially presented with post dialysis sbps in 80s from baseline likely in setting of volume depletion from dialysis and ongoing gib x week less likely hypovolemia due to sepsis given patient is afebrile with no leukocytosis or signs of infection blood pressures improved s p unit of packed red blood cells in the emergency department and remained stable throughout remainder of admission hepatomegaly liver edge palpated cm below the r costal margin with imaging suggestive of cirrhosis and congestive hepatopathy she has negative hepatitis serologies and remote history of heavy alcohol use in her a more likely cause for hepatic congestion is her right sided heart failure however she has a slightly elevated inr which may be secondary to poor nutritional intake given her age and comorbidities her liver function tests are largely within normal limits ruq us on revealed enlarged liver with heterogeneous echotexture unchanged from prior studies she should have f u of liver function with pcp with consideration for referral to hepatology atrial fibrillation chads2 vasc score not currently on anticoagulation given history of gi and av fistula bleed she was monitored on telemetry and remained in atrial fibrillation metoprolol was held during this admission in the setting of hypotension per gi there is no long term contraindication to anticoagulation but would start after egd chronic issues anuric end stage renal disease s p cadaveric donor renal transplant complicated by allograft failure re initiated on hd last dialysis session on with cxr showing moderate pulmonary edema patient continued taking herhome nephrocaps cinacalcet and calcium acetate during this admission and was on a renal diet diastolic congestive heart failure complicated by right heart failure the patient has moderate diastolic dysfunction with preserved ef per last tte in s elevated right heart pressures as well as rv systolic dysfunction seen on tte as well as right heart cath patient mildly volume up on exam but satting well on home o2 requirement chronic obstructive pulmonary disease patient last had pulmonary function testing in which showed moderately reduced fvc moderately severe reduction in fev1 with elevated fev1 fvc thought to reflect moderately severe obstructive disease she was monitored with o2 telemetry during this admission she continued taking her home albuterol neb q4h as needed and advair twice a day she continued using her home oxygen nc gerd patient takes po omeprazole 40mg qd at home was switched to iv pantoprazole 40mg bid on admission in setting of melena then switched back to po pantoprazole 40mg bid upon discharge esrd hd as outpatient last dialysis session pending labs please f u blood culture x negative growth pending discharge hepatomegaly appreciated on exam with ruqus congestive hepatopathy please continue to trend and workup liver disease as outpatient copd patient continued on home continuous without any desaturation code full confirmed communication sister and hcp transitional issues gi bleed patient needs repeat egd in weeks to follow up on ulcerations in cardia would recommend colonoscopy at same time given prior colonoscopy prep was fair and revealed an 8mm sessile polyp that was not removed bid ppi until follow up endoscopy follow up biopsies from egd atrial fibrillation consider initiation of anti coagulation after follow up egd as no long term contraindications from gi medications on admission the preadmission medication list may be inaccurate and requires futher investigation fluticasone salmeterol diskus inh ih bid lidocaine prilocaine appl tp 3x week nephrocaps cap po daily albuterol sulfate mcg actuation inhalation q6h aspirin mg po daily metoprolol succinate xl mg po daily calcium acetate mg po tid w meals omeprazole mg po daily terconazole vaginal qhs prn vaginitis discharge medications albuterol sulfate mcg actuation inhalation q6h aspirin mg po daily calcium acetate mg po tid w meals fluticasone salmeterol diskus inh ih bid lidocaine prilocaine appl tp 3x week nephrocaps cap po daily metoprolol succinate xl mg po daily pantoprazole mg po q12h rx pantoprazole mg tablet s by mouth twice daily disp tablet refills discharge disposition home discharge diagnosis primary diagnosis upper gi bleed erosive gastritis gastric ulcers secondary diagnosis hypotension acute on chronic anemia discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms it was a pleasure taking care of you during your hospitalization at you were admitted to the hospital because of low blood pressure low red blood cell count and dark stool positive for blood melena your symptoms were thought to be due to bleeding in your gastrointestinal tract you were treated with an intravenous proton pump inhibitor pantoprazole to decrease stomach acidity you underwent upper endoscopy study to look for possible source of bleeding which showed ulcers in your stomach and inflammation of your stomach lining gastritis biopsies of your stomach tissue were taken results of which are pending we would like you to continue taking pantoprazole twice a day to help protect your stomach lining and to return for a repeat endoscopy in weeks to assess for healing of the ulcers with colonoscopy at the same time please continue taking your home medications please follow up with your pcp and outpatient specialists on discharge we wish you a speedy recovery your care team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies allopurinol and derivatives penicillins ace inhibitors attending chief complaint hypotension sbp in major surgical or invasive procedure egd capsule endoscopy history of present illness mrs is a y o woman with past history of esrd from focal segmental glomerulosclerosis s p failed transplant on hd copd gerd w out pud atrial fibrillation not on coumadin congestive heart failure and severe right heart failure pulmonary hypertension recurrent cdiff infection upper gi bleed from erosive gastritis and gastric ulcer chronic anemia who was transferred from her dialysis center to the ed for hypotension with sbp in s she was recently admitted to in with melena hypotension and acute on chronic anemia and was found to have upper gi bleed from two linear ulcerations in the cardia on the day of admission she was found to have hypotension with sbp in s during dialysis so she was sent to the ed she reported dark stools for approximately a week which she attributed to recurrent c dif she denied dizziness chest pain shortness of breath abdominal pain diarrhea she noted significant recent distention of her abdomen and some peripheral edema she denied jaundice in the past on review of her systems she admits to shortness of breath and dyspnea on exertion patient was recently evaluated in outpatient clinic for new liver disease she was noted to have an enlarged liver and considered to have congestive hepatopathy her most recent liver function tests show an alkaline phosphatase of with a normal alt and ast of and respectively negative test for her serum ace and negative hepatitis b and hepatitis c markers normal c3 and c4 rheumatoid factor is increased to she has elevated igg alpha antitrypsin was mildly elevated an ultrasound of the liver showed dilated inferior vena cava and hepatic veins consistent with right heart failure she had trace ascites at that time in of note a chest ct from showed innumerable mediastinal lymph nodes mildly enlarged indeterminate difficult to exclude lymphoma or other etiologies in the ed initial vitals ra exam was notable for gauaic dark stool labs were notable for wbc h h platelets ptt inr alt ap tbili alb ast ldh na k cr ca mg p lactate diagnostic para wbc rbc poly lymph protein glucose patient was given octreotide acetate mcg iv q8h ciprofloxacin mg iv once pantoprazole mg iv once 2units prbcs imaging included ct abdomen and cxr see below for details vitals prior to transfer ra ros per hpi denies fever chills night sweats headache vision changes rhinorrhea congestion sore throat cough chest pain abdominal pain nausea vomiting diarrhea constipation dysuria hematuria past medical history past medical history esrd s p transplant fsgs by biopsy on hd s p dcdkd in c b chronic allograft nephropathy in with reinitiation of hd on mwf schedule complicated by intradialytic hypotension atrial fibrillation not on anticoagulation due to significant gastrointestinal as well as av fistula site bleeding bradycardia copd on home oxygen fev1 of predicted diastolic chf last tte in with ef symmetric lvh dilated rv with borderline systolic function and severe pulmonary htn small septum secundum claudication with concern for peripheral vascular disease no formal arterial duplex studies on record gerd gout hsv ii htn pulmonary htn no prior documentation but likely group tobacco abuse anemia gi bleed recurrent c diff colitis initially diagnosed in and treated with flagyl 500mg x days again in s p flagyl 500mg x days persistent infection still later in treated with vanco 125mg po x14days h o syphilis h o breast cysts past surgical history open cholecystectomy tubal ligation with incision from midline to pubis exploratory laparotomy for ovarian cyst negative social history family history mother on dialysis from diabetes mellitus niece with esrd s p transplant physical exam physical exam on admission vital afebrile ra general well appearing in nad heent exostropia bilaterally sclera anicteric cardiac irregular with no excess sounds appreciated lungs unlabored resp adequate air movement prolonged expiratory phase abdomen soft distended non tender to palpation hepatomegaly is present extremities trace pitting edema in bilaterally warm and well perfused tender to palpation neurology no asterixis no sensory or motor deficits noted physical exam on discharge vs ra general nad pleasant sitting comfortably in chair heent op clear anicteric sclera apparent proptosis and exotropia pale conjunctiva cards irregularrly irregular no murmurs rubs gallops pulm ctab no wheezes rales rhonchi abdomen soft mild epigastric tenderness mild distension but soft normoactive bowel sounds no organomegaly extremities warm no edema access lue avg good thrill bruits heard neuro no asterixis pertinent results lab results on admission 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 alt ast ld ldh alkphos totbili 45am blood albumin calcium phos mg 30pm blood hgb calchct 00pm ascites wbc polys lymphs mesothe macroph other 00pm ascites totpro glucose pertinent interval labs 08am blood ca125 10pm ascites totpro albumin 47am blood albumin calcium phos mg igg subclasses test result reference range units immunoglobulin g subclass h mg dl immunoglobulin g subclass mg dl immunoglobulin g subclass mg dl immunoglobulin g subclass h mg dl immunoglobulin g serum h mg dl lab results on discharge 08am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 08am blood ptt 08am blood glucose urean creat na k cl hco3 angap 08am blood alt ast alkphos totbili 08am blood albumin calcium phos mg radiology ct abdomen pelvis abnormal soft tissue prominence in the bilateral adnexa right greater than left recommend correlation with prior clinical history including prior fallopian tube exploration and cytology results from recent paracentesis if results are nondiagnostic an mri of the pelvis with iv contrast should be considered to exclude underlying malignancy especially in light of enlarged retroperitoneal lymph nodes cirrhotic liver morphology moderate amount of nonhemorrhagic ascites prominent intramural fat in the cecum and ascending reflect chronic inflammation right lower quadrant transplanted kidney is abnormal in appearance atrophic with loss of normal corticomedullary differentiation renal osteodystrophy recommendation s correlation with clinical history and cytology results consider pelvis mri for further evaluation cxr mild pulmonary edema no focal consolidation pathology cytology ascitic fluid negative for malignant cells predominantly blood with scattered admixed mesothelial cells and lymphocytes gi endoscopy egd large hiatal hernia was noted otherwise normal egd to third part of the duodenum brief hospital course mrs is a y o woman with complicated past history most notable for severe right heart failure pulmonary hypertension upper gi bleed from erosive gastritis and gastric ulcer and esrd from focal segmental glomerulosclerosis s p failed transplant on hd who was transferred from her dialysis center to the ed for hypotension with sbp in in setting of melena ct abdomen pelvis performed in ed is notable for abnormal soft tissue prominence in bilateral adnexa r l cytology of ascitic fluid negative for malignancy and diagnostic paracentesis was negative for sbp egd only notable for hiatal hernia no bleed she had an additional episode of melena on and the decision was made to proceed with capsule endoscopy on the preliminary read showed some possible avms in the jejunum but no active source of bleeding she had no further episodes of melena her blood pressure improved to sbp 100s and her hemoglobin was stable we planned to do an echocardiogram during this admission to reassess her right heart failure but we were unable to get this study done and she was eager to be discharged she received u prbc throughout stay discharge hgb was she was hemodynamically stable hypotension acute on chronic anemia melena one week history of melena prior to presentation in context of recent admission for upper gi bleed with endoscopy showing linear gastric ulcer as well as erosive gastritis as well as prior history of recurrent c diff she was initially treated with iv pantoprazole q12h octreotide gtt and ciprofloxacin mg iv q24h due to concern for ugib egd only notable for hiatal hernia no bleed hence octreotide was discontinued at that time she had an additional episode of melena on and the decision was made to proceed with capsule endoscopy on the preliminary read showed some possible avms in the jejunum but no active source of bleeding she had no further episodes of melena her blood pressure improved to sbp 100s and her hemoglobin was stable on discharge ascites ct abdomen notable for cirrhotic liver morphology moderate ascites and abnormal soft tissue prominence in bilateral adnexa r l she has had prior work up with negative hepatitis b and c serologies no alpha antitrypsin deficiency normal c3 c4 differential diagnosis for her includes cardiac cirrhosis given elevated protein at and her history of r heart failure which would be consistent with elevated saag of on meig s syndrome malignancy is also under consideration given the fullness in adnexa and ascites in setting of an elevated ca cytology negative for malignant cells typically would consider mri pelvis with contrast to further evaluate however patient is very claustrophobic please discuss further work up as an outpatient elevated igg igg was recently found to be elevated to raising concerns for plasma cell disorders leukemia and lymphoma among other disease especially with abnormal findings on ct chest and abdomen igg and s total igg were found to be elevated on the sub type analysis please consider immunology referral anuric end stage renal disease s p cadaveric donor renal transplant complicated by allograft failure re initiated on hd continue dialysis per renal team atrial fibrillation chads2 vasc score not currently on anticoagulation given history of gi and av fistula bleed home metoprolol was held due to concern for hypotension diastolic congestive heart failure complicated by right heart failure the patient has moderate diastolic dysfunction with preserved ef per last tte in s elevated right heart pressures as well as rv systolic dysfunction seen on tte as well as right heart cath patient mildly volume up on exam but saturating well on home o2 requirement we had planned on obtaining a repeat echocardiogram however this was not done and patient was eager to leave home metoprolol was held due to concern for hypotension chronic obstructive pulmonary disease patient last had pulmonary function testing in which showed moderately reduced fvc moderately severe reduction in fev1 with elevated fev1 fvc thought to reflect moderately severe obstructive disease she was continued on home albuterol neb q4h as needed and advair twice a day gerd patient takes po omeprazole 40mg qd at home which was switched to iv pantoprazole 40mg bid in setting of melena transitional issues findings of new ascites and adnexal fullness on ct are concerning for malignancy especially in setting of elevated ca to though it is noted that ca is nonspecific and shouldn t be used as screening test for ovarian cancer cytology negative please consider mri to further evaluate though patient reports she is extremely claustrophobic capsule study results are pending at the time of discharge please follow up and refer to outpatient gi or book further testing procedures as needed hgb on discharge is consider outpatient echocardiogram given new ascites known right heart failure and last echo given recent finding of elevated total igg on testing sent by outpatient hepatology igg subclasses were sent and revealed elevated igg1 and igg further workup per outpatient hepatology code full communication sister and hcp on admission the preadmission medication list is accurate and complete albuterol sulfate mcg actuation inhalation q6h aspirin mg po daily calcium acetate mg po tid w meals fluticasone salmeterol diskus inh ih bid lidocaine prilocaine appl tp 3x week nephrocaps cap po daily metoprolol succinate xl mg po daily pantoprazole mg po q12h discharge medications ciprofloxacin hcl mg po q24h duration days rx ciprofloxacin hcl cipro mg tablet s by mouth once a day disp tablet refills albuterol sulfate mcg actuation inhalation q6h aspirin mg po daily calcium acetate mg po tid w meals fluticasone salmeterol diskus inh ih bid lidocaine prilocaine appl tp 3x week metoprolol succinate xl mg po daily nephrocaps cap po daily pantoprazole mg po q12h discharge disposition home discharge diagnosis primary upper gi bleed secondary congestive heart failure esrd discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms you were admitted to because your blood pressure was low as you were recently in the hospital because of a bleeding ulcer in your stomach we wanted to make sure that you are no longer bleeding therefore we did a upper endoscopy which did not show any bleeding however you had some more dark stools and your blood counts dropped hence we gave you blood and did a capsule endoscopy which can look further for sources of bleeding a very preliminary look at the study did not show any active bleeding but showed some possible culprits in the first part of your small intestine the full report will be done soon and should be available to your pcp at your follow up appointment we also noticed that your belly was very distended with fluid this can happen for many reasons for instance right sided heart failure which you have a history of causing liver problems a sick liver or cancer we took some of the fluid out to both take a closer look and to make you feel better we also did a ct scan and obtained an ultrasound of your heart echo the ct scan showed that you have some fullness in your adnexa where your ovaries and tubes are and we are waiting for the results of the fluid we sent out to look for cancer we also planned to check an echocardiogram an ultrasound of your heart unfortunately we were not able to get this study done for you while you were here this can be ordered by your pcp or your cardiologist and done as an outpatient please follow up with your primary care doctor this week please also follow up with your liver doctor in the next few weeks best wishes your team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies allopurinol and derivatives penicillins ace inhibitors lisinopril attending chief complaint fistula ulceration major surgical or invasive procedure av fistula revision guided paracentesis history of present illness w pmh of esrd s p failed renal transplant on hd afib copd on 3l o2 chf pulmonary htn cryptogenic cirrhosis presents with ulceration over her av fistula patient notes that the ulcer developed one week ago after she had removed tape from the site of ulcer note she reports that she normally applies cream to the fistula site and covers it with tape ulceration then noticed by outpatient hd rn two days ago and advised patient to come in however patient refused at that time this morning she went to dialysis who referred her here as they were unable to access her hd site her last hd session was she reports that the ulceration has been present for approximately one week and that she has been applying lidocaine prilocaine cream to the area it is pruritic she denies purulence erythema or discharge no fevers chills chest pain shortness of breath in the ed initial vital signs were t98 hr94 bp101 rr sao2 nasal cannula exam notable for l arm fistula w palpable thrill cm healed ulceration with mild tenderness no erythema or discharge rrr scattered wheezes bilaterally breathing comfortably abdomen distended tense non tender edema bilaterally labs were notable for cr hgb wbc ap lfts normal albumin inr studies performed include cxr demonstrated pulmonary vascular congestion diffuse bilateral interstitial edema small right pleural effusion bilateral linear atelectasis patient was given midodrine calcium acetate gabapentin mg albuterol neb diskus tylenol she had an hd session prior to arriving on the floor vitals on transfer 3l upon arrival to the floor the patient was hungry and wanted to eat also endorsed pain and numbness in her right foot which she often has after dialysis denies abdominal pain review of systems per hpi otherwise past medical history past medical history esrd s p transplant fsgs by biopsy on hd s p dcdkd in c b chronic allograft nephropathy in with reinitiation of hd on mwf schedule complicated by intradialytic hypotension atrial fibrillation not on anticoagulation due to significant gastrointestinal as well as av fistula site bleeding bradycardia copd on home oxygen fev1 of predicted diastolic chf last tte in with ef symmetric lvh dilated rv with borderline systolic function and severe pulmonary htn small septum secundum claudication with concern for peripheral vascular disease no formal arterial duplex studies on record gerd gout hsv ii htn pulmonary htn tobacco abuse anemia gi bleed recurrent c diff colitis h o syphilis h o breast cysts pelvic mass ascites cryptogenic cirrhosis past surgical history open cholecystectomy tubal ligation with incision from midline to pubis exploratory laparotomy for ovarian cyst negative social history family history she denies a family history of liver disease family history of father with atherosclerotic cvd mother with diabetes on dialysis no history of cancer physical exam admission physical exam vs 3l general aox3 nad heent scleral icterus mmm neck normal rom cardiac regular rate and rhythm normal s1 and s2 lungs coarse crackles in left lower lung fields otherwise clear to auscultation abdomen distended tense abdomen dull to percussion shifting dullness nontender to palpation extremities lower extremity edema pitting to mid shins skin lue fistula with 2cm area of ulceration without active pus or overlying erythema neurologic cn2 intact strength throughout normal sensation discharge physical exam vs ra general aox3 nad heent scleral icterus significant exotropia od mmm neck normal rom cardiac regular rate and rhythm normal s1 and s2 lungs breathing nonlabored cta anteriorly abdomen distended abdomen dull to percussion somewhat tense nontender hypoactive bs extremities wwp no extremity edema skin lue fistula with surgical dressing c d i neurologic cn2 intact strength throughout normal sensation pertinent results admission labs 05am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 05am blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 05am blood ptt 05am blood plt 05am blood glucose urean creat na k cl hco3 angap 05am blood alt ast ld ldh alkphos totbili 05am blood albumin calcium phos mg discharge labs 35am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 35am blood plt 35am blood glucose urean creat na k cl hco3 angap 35am blood calcium phos mg imaging cxr mild to moderate pulmonary vascular congestion diffuse bilateral interstitial edema and trace right pleural effusion suggest volume overload bilateral linear atelectasis paracentesis technically successful ultrasound guided therapeutic paracentesis yielding l of clear straw colored ascitic fluid brief hospital course w pmh of esrd s p failed renal transplant on hd afib copd on 3l o2 chf pulmonary htn cryptogenic cirrhosis presenting with ulceration over her av fistula avf ulceration new ulceration on site of avf perhaps from patient self applying tape over the fistula underwent fistula revision esrd s p ecd kidney transplant in c b chronic allograft nephropathy chronic focal segmental glomerulosclerosis was on dialysis from had a transplant in but failed in resumed dialysis in mwf with lue avf continued home medications had session of hd prior to discharge without complications resume mwf schedule anemia likely from low epo and anemia of chronic disease continued epo 000u qhd cryptogenic cirrhosis perhaps cardiac cirrhosis in setting of right sided heart failure complicated by portal hypertension with ascites and splenomegaly up to date on variceal and hcc screening based on most recent hepatology note last egd found large hiatal hernia has q2 week paracentesis due again on received guided paracentesis on with 4l fluid removed concern for gyn malignancy concern for ovarian or other malignancy as a cause of ascites elevated ca on patient was offered mri as an inpatient both sedated or regular with premedication but declined despite counseling of the risks she reports that she did not want to be out of it with breathing support but also could not be enclosed she raised the idea of an open mri and discussed that image quality is not as good but patient was adamant primary care doctor was contacted regarding open mri aflutter afib was previously on coumadin and carvedilol the coumadin was stopped in secondary to frequent fistula bleeding events it was restarted in risk of hemorrhagic stroke is higher with warfarin use in hd patients no current anticoagulation copd on 3l home o2 since continued home management chronic diastolic heart failure pulmonary hypertension seen by cardiology in not on any cardiac meds due to hypotension unable to aggressively remove fluid with uf due to hypotension as well gerd continued home pantoprazole transitional issues patient needs open mri to evaluate for possible malignancy code status presumed full code emergency contact hcp alternate contact is sister medications on admission the preadmission medication list is accurate and complete albuterol neb soln neb ih q6h prn wheeze albuterol inhaler puff ih q6h prn wheeze fluticasone salmeterol diskus inh ih bid nephrocaps cap po daily calcium acetate mg po tid w meals pantoprazole mg po q24h hydroxyzine mg po q4h prn pruritis discharge medications albuterol neb soln neb ih q6h prn wheeze albuterol inhaler puff ih q6h prn wheeze calcium acetate mg po tid w meals fluticasone salmeterol diskus inh ih bid hydroxyzine mg po q4h prn pruritis nephrocaps cap po daily pantoprazole mg po q24h discharge disposition home discharge diagnosis av fistula ulceration esrd on hd cryptogenic cirrhosis copd on home o2 atrial fibrillation flutter portal hypertension with ascites and splenomegaly chronic diastolic heart failure pulmonary hypertension anemia discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear ms you were admitted to the hospital because you had a problem with your fistula it was fixed in a procedure called a fistula revision you had a dialysis session on that went well so you can continue your regular dialysis schedule you had a lot of fluid in your abdomen that was removed by our radiology team you need an mri of your abdomen to help figure out why you have all of this fluid building up you were offered this test while you were here but you felt claustrophobic and you did not want to be sedated either instead you were hoping to have an open mri please talk to your primary care doctor about scheduling this important test please see your follow up appointments below it was a pleasure caring for you and we wish you the best your team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies allopurinol and derivatives penicillins ace inhibitors lisinopril attending chief complaint sob major surgical or invasive procedure r femoral cvl paracentesis history of present illness w pmhx of esrd s p failed renal transplant now on hd afib copd on 3l o2 chf pulmonary htn cryptogenic cirrhosis who presents with shortness of breath and cough patient is a poor historian so history is obtained via ed dash and limited conversation with patient reports has been feeling feverish at home reports has been having a productive cough over the last week patient lives alone she woke up this morning feeling worse and called her daughter who was worried about her breathing and eventually convinced her to come to the emergency room patient reports her blood pressure is often low in the denies any chest pain at this time recent history notable for lvp on with 8l fluid removed and hd on with additional 3l removed in ed initial vs nasal cannula exam none documented in ed labs significant for cbc chem cr k mg lactate patient was given iv vancomycin mg ordered started stop po acetaminophen mg ivf ns ml ordered started ivf ns ml ordered started stop iv piperacillin tazobactam g ordered started iv albumin 5g 50ml g imaging notable for cxr moderate pulmonary edema worse in the interval with increased size of right pleural effusion now moderate in extent probable small left pleural effusion as well bibasilar airspace opacities more so on the right could reflect compressive atelectasis though infection is difficult to exclude right femoral line was placed in the ed with initiation of levophed vs prior to transfer nasal cannula on arrival to the micu patient reports feeling much improved she provides the history as above but does not elaborate further denies any abdominal pain or chest pain breathing is at her baseline no recent sick contacts per review of omr medications patient would have completed a prolonged month prednisone taper on if taking as prescribed past medical history past medical history esrd s p transplant fsgs by biopsy on hd s p dcdkd in c b chronic allograft nephropathy in with reinitiation of hd on mwf schedule complicated by intradialytic hypotension atrial fibrillation not on anticoagulation due to significant gastrointestinal as well as av fistula site bleeding bradycardia copd on home oxygen fev1 of predicted diastolic chf last tte in with ef symmetric lvh dilated rv with borderline systolic function and severe pulmonary htn small septum secundum claudication with concern for peripheral vascular disease no formal arterial duplex studies on record gerd gout hsv ii htn pulmonary htn tobacco abuse anemia gi bleed recurrent c diff colitis h o syphilis h o breast cysts pelvic mass ascites cryptogenic cirrhosis past surgical history open cholecystectomy tubal ligation with incision from midline to pubis exploratory laparotomy for ovarian cyst negative social history family history she denies a family history of liver disease family history of father with atherosclerotic cvd mother with diabetes on dialysis no history of cancer physical exam admission physical exam vitals afebrile hr 5l nc general alert oriented appears in pain moving around the bed heent sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs diffuse harsh rhonchi and end expiratory wheezes decreased breath sounds right base midway up lungs cv tachycardic irregular abd bs distended soft non tender no rebound tenderness or guardin ext left leg cooler compared with right leg no clubbing cyanosis or edema lue fistula with palpable thrill audible bruit skin xerotic skin no ulcerations or erythema noted neuro aox3 moving all extremities discharge physical exam on exam patient was still pulses in absent in bilateral carotid arteries absent withdrawal to painful stimuli pupils fixed dilated non responsive to light bilaterally no heart sounds or breath sounds appreciated on auscultation no chest rise appreciated on palpation time of death was patient s family was present at the time of death pertinent results labs on admission 19pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 19pm blood neuts lymphs monos eos baso nrbc im absneut abslymp absmono abseos absbaso 20am blood 19pm blood glucose urean creat na k cl hco3 angap 19pm blood alt ast alkphos totbili 19pm blood albumin calcium phos mg 26pm blood po2 pco2 ph caltco2 base xs notable labs 55pm ascites tnc rbc polys lymphs monos basos 55pm ascites totpro albumin pm blood culture source line fem line final report blood culture routine final no growth pm peritoneal fluid peritoneal fluid final report gram stain final per 1000x field polymorphonuclear leukocytes no microorganisms seen this is a concentrated smear made by cytospin method please refer to hematology for a quantitative white blood cell count fluid culture final no growth anaerobic culture final no growth labs on discharge 29am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 25am blood neuts monos eos baso nrbc im absneut abslymp absmono abseos absbaso 29am blood glucose urean creat na k cl hco3 angap 29am blood alt ast ld ldh alkphos totbili 29am blood calcium phos mg 58am blood po2 pco2 ph caltco2 base xs 58am blood lactate w pmhx of esrd s p failed renal transplant now on hd afib copd on 3l o2 chf pulmonary htn cryptogenic cirrhosis who presents with fever shortness of breath and cough admitted to icu with sepsis and who eventually died due to complications from ongoing hypotension esrd and seizure icu course mixed shock presented with fever leukocytosis in setting of known systolic heart failure and low cvo2 no lactate elevation to suggest hypoperfusion most likely source is pulmonary given cough cxr findings infected ascites less likely since she has not had acute abdominal pain and exam was benign had paracentesis on that was negative for sbp treated with vancomycin cefepime azithromycin possible hives to penicillins tte was performed on which showed dilated and hypokinetic right ventricle with pressure volume overload signs of pulmonary hypertension severe tricuspid regurgitation w nl lv function patient has known systolic dysfunction with baseline sbps in the community pt began to have diarrhea and we sent analysis for cdiff and she was found to be positive the pt was started on oral vanc to treat patient required pressor support for most of her admission and uptitration of midodrine after lack of improvement after treatment of possible pulmonary infection as above and after decline in mental state as below family eventually decided to focus on comfort care and pressors were discontinued seizure activity decline in responsiveness and alertness from to eeg started in and found to be in status epilepticus and given iv ativan which terminated her seizure she continued to be very unresponsive after eeg resolution of the seizure she was started on lacosamide flagyl and cefepime were discontinued given that these can lower the seizure threshold goals of care given persistent critically ill state and inability to wean off pressors family expressed interest in moving patient towards cmo the family did express interest in ct head and eeg to see if there was easily reversible cause of her encephalopathy she was found to be in status epilepticus and this was treated as above however given that mental status did not improve even after breaking from status epilepticus family decided to convert patient to cmo respiratory failure infection iso copd less likely copd exacerbation so steroids were not started pt had 1l taken off on paracentesis and renal ultrafiltrated to remove additional volume given pleural effusions dialysis on hd mwf continued per normal schedule attempted to remove larger volumes through ultrafiltration in an attempt to off load right heart given severe dysfunction seen on echo cryptogenic cirrhosis c b ascites splenomegaly etiology thought to be possibly cardiac from right sided chf currently receiving frequent lvp last on with 8l removed pt also had paracentesis in unit on taking off 1l w o signs of sbp last egd in without varices chronic issues afib aflutter afib not on anticoagulation in the setting of past fistula and gi bleeding hr 100s irregular not currently on rate control presumably limited by outpatient hypotension rates were not an issue during her hospital stay chronic diastolic heart failure pulmonary hypertension last tte in with moderate lv diastolic dysfunction severe phtn not on medications as limited by hypotension pt had a tte in the hospital which showed pulmonary hypertension nl ef w severe tricuspid regurgitation and global hypokinesis concern for gyn malignancy mri with e o matted appearing ovaries loss of normal architecture elevated ca cysts with ascites evaluated by dr in obgyn unlikely to be a surgical candidate in the setting of multiple medical comorbidities plan was for ongoing discussion in the outpatient setting gerd continued pantoprazole medications on admission the preadmission medication list may be inaccurate and requires futher investigation fluticasone salmeterol diskus inh ih bid nephrocaps cap po daily pantoprazole mg po q24h albuterol neb soln neb ih q6h prn wheeze hydroxyzine mg po q4h prn itching midodrine mg po before hd cinacalcet mg po daily discharge medications n a discharge disposition expired discharge diagnosis mixed shock seizure discharge condition deceased discharge instructions n a 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 hemothorax major surgical or invasive procedure left vats evacuation of hemothorax and partial decortication bronchoscopy with lavage bronchoscopy right picc placement history of present illness with pmh of smoking for years quit years ago copd peripheral vascular disease requiring multiple stents aortic valve disease s p tavr procedure on asa and plavix at the in who presents to from for escalation of care of respiratory distress in the setting of a left sided hemothorax following thoracentesis performed earlier today he was having productive yellow sputum fever and fatigue for which he was empirically treated with azithromycin however he did not improve on the antibiotics and went to the ed for further evaluation at that time he underwent a ct scan of the chest which showed pneumonia of the lll with some cavitation in the lul as well as a l pleural effusion w compressive atelectasis of the lll of the lung at that time he was admitted to the hospital started on iv antibiotics and was consulted for thoracentesis under ultrasound guidance a left sided thoracentesis was performed with removal of purulent fluid which was sent for gram stain which demonstrated multiple gram positive and gram negative organisms during the procedure thoracic surgery was consulted and the decision was made to leave a drainage catheter in the left chest as the fluid was grossly purulent on aspiration however when returning to place the drainage catheter the thoracentesis catheter had been dislodged under ultrasound guidance the fluid collection was re identified and a repeat needle puncture was performed but this time there was purulent fluid as well as blood was aspirated an catheter was placed into the left chest there was no significant drainage and the catheter was subsequently removed cxr afterwards shows mild infiltrate in the left lung but overall significantly improved a couple hours after his procedure while on the medical floor the patient started to have hemoptysis and started to desaturate he was intubated and transferred to the icu at that time the airway was without blood a suction catheter had been passed without gross blood suctioned and he was appropriately sedated cxr then showed a loculated dense fluid within the left chest consistent with a hemothorax while at he received 2u of prbcs 2u of ffp and 2u of platelets his antibiotics were broadened to meropenem he was then transferred to for thoracic surgery evaluation and further management on arrival at the patient started to require pressors to maintain maps cxr was obtained and showed near complete opacification of the left hemithorax labs were significant for a hgb of and hct creatinine elevated lfts alt ast inr at this time there was concern for hemorrhagic shock with bleeding into the left thorax and the patient was being prepped for an operative procedure past medical history pmh former smoker copd pvd aortic valve stenosis psh multiple peripheral vascular stenting procedures and stenting of the mesenteric vessels tavr in social history family history remarkable for patient s father having died of gastric cancer at the patient s mother died of natural causes at physical exam discharge physical exam hr data last updated temp tm bp hr rr o2 sat o2 delivery ra wt lb kg fluid balance last updated last hours total cumulative 580ml in total 120ml po amt 120ml out total 700ml urine amt 700ml last hours total cumulative 3ml in total 7ml po amt 810ml iv amt infused 7ml out total 1300ml urine amt 1300ml gen x nad aaox3 cv x rrr murmur resp x breaths unlabored no inc wob abdomen x soft distended tender rebound guarding wound x incisions clean dry intact left ct sites with some underlying firmness no excessive drainage ext x warm tender edema rt foot with diminished sensation to sharp and dull stimuli below ankle rt foot with dopplerable pulses monophasic biphasic dp below ankle pertinent results 15am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 15am blood plt 15am blood glucose urean creat na k cl hco3 angap 44am blood estgfr using this 28am blood alt ast ck cpk alkphos totbili 15am blood calcium phos mg cxr impression comparison to a m the pigtail catheter on the left was removed no evidence of pneumothorax stable extent of the left pleural fluid collection stable appearance of the right lung arterial non invasives findings right brachial pressure not obtained due to line placement left brachial pressure mmhg right lower extremity posterior tibial artery pressure dorsalis pedis artery pressure toe pressure right abi right tbi doppler waveforms common femoral artery monophasic femoral artery monophasic popliteal artery monophasic posterior tibial artery monophasic dorsalis pedis artery monophasic pulsed volume waveforms low thigh severely abnormal calf severely abnormal ankle severely abnormal metatarsal severely abnormal digit severely abnormal left lower extremity posterior tibial artery pressure dorsalis pedis artery pressure toe pressure left abi left tbi doppler waveforms common femoral artery biphasic femoral artery monophasic popliteal artery monophasic posterior tibial artery monophasic dorsalis pedis artery monophasic pulse volume waveforms low thigh severely abnormal calf severely abnormal ankle severely abnormal metatarsal severely abnormal digit severely abnormal brief hospital course patient is a year old male with history of cad aortic stenosis s p tavr maintained on asa and plavix treated for cap since the end of presenting as transfer from with respiratory failure hemoptysis and shock presentation was likely secondary to hemorrhagic shock with bleeding into the left thorax with likely component of septic shock as well secondary to left lung empyema on he underwent a left vats evacuation of hemothorax and partial decortication bronchoscopy with lavage icu stay transferred to the floor brief summary by system cv initially required pressor support in the icu post op which was gradually weaned as tolerated cardiology involved for mildly elevated troponin that ultimately plateaued pt has a history of pad and had rle mottling and concern for ischemia post op vascular surgery was consulted and he was started on a therapeutic heparin drip which he was maintained on until at which point he was transitioned to prophylactic sqh for his chronic cardiovascular history he was maintained on asa statin and plavix metoprolol 50mg q6h was given for bp control and amlodipine 10mg was started as patient began to mobilize toward the end of his hospital stay he endorsed right foot numbness that has a chronic component given his extensive vascular history he underwent arterial non invasive studies on with rt abi lt abi he will have close follow up with vascular surgery on discharge resp patient remained intubated postoperatively until pod4 surgical chest tubes were placed at the time of operation placed additional left apical chest tube on for improved drainage output was monitored daily one chest tube was removed per day on post pull cxrs demonstrated no ptx the patient was breathing comfortably and saturating well on room air at the time of discharge he will continue abx for empyema per below gi patient underwent evaluation by the speech swallow team on multiple occasions was cleared for ground solids and thin liquids meds whole or crushed in puree at the time of discharge renal patient was followed by the renal service and required intermittent hemodialysis for oliguric until he ultimately achieved full recovery of renal function with normalization of creatinine and no longer required dialysis nephrotoxic meds including home lisinopril were held placed on flomax when foley catheter was removed to aid in voiding id arrived from osh on meropenem over the course of his hospital stay he was followed by the infectious disease service for management of his empyema initial sputum cx with growth of pseudomonas and enterobacter and pleural fluid with fusobacterium and parvimonas cavitary pneumonia likely polymicrobial infection given that he was a fe he was also ruled out for tb he was transitioned to a regimen of cefepime and flagyl with scheduled outpatient follow up treatment with iv cefepime and po flagyl to continue on discharge with projected end date of heme on transfer and postoperatively patient received 5u prbc and 1plt he remained hemodynamically stable he was also transfused 1u prbcs on and for low hct with appropriate response he was evaluated by physical and occupational therapy who recommended placement in acute rehab facility at time of discharge medications on admission the preadmission medication list may be inaccurate and requires further investigation metoprolol succinate xl mg po daily clopidogrel mg po daily aspirin mg po daily atorvastatin mg po qpm omeprazole mg po bid lisinopril mg po daily discharge medications acetaminophen mg po q8h amlodipine mg po daily bisacodyl mg pr qhs prn constipation second line cefepime g iv q12h projected end date heparin unit sc bid lansoprazole oral disintegrating tab mg po daily metoprolol tartrate mg po q6h metronidazole mg po ng q8h projected end date oxycodone immediate release mg po q6h prn pain moderate reason for prn duplicate override alternating agents for similar severity polyethylene glycol g po daily tamsulosin mg po qhs aspirin mg po daily atorvastatin mg po qpm clopidogrel mg po daily held lisinopril mg po daily this medication was held do not restart lisinopril until discussing with your pcp cardiologist discharge disposition extended care facility discharge diagnosis left hemothorax and empyema septic shock ischemic left lower extremity discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions you were admitted to the hospital for lung surgery and you ve overall recovered well you are now ready for discharge continue to use your incentive spirometer times an hour while awake check your incisions daily and report any increased redness or drainage cover the area with a gauze pad if it is draining you may need pain medication once you are home but you can wean it over the next week as the discomfort resolves make sure that you have regular bowel movements while on narcotic pain medications as they are constipating which can cause more problems use a stool softener or gentle laxative to stay regular no driving while taking narcotic pain medication take tylenol on a standing basis to avoid more opioid use continue to stay well hydrated and eat well to heal your incisions shower daily wash incision with mild soap water rinse pat dry no tub bathing swimming or hot tubs until incision healed no lotions or creams to incision site walk times a day and gradually increase your activity as you can tolerate please follow up with your cardiologist on discharge as we have adjusted some of your home medications including metoprolol and also added a new medication called amlodipine and held lisinopril please also follow up with dr surgeon regarding your lower extremity vascular disease call dr dr dr if you experience fevers or chills increased shortness of breath chest pain or any other symptoms that concern you followup instructions

name unit no admission date discharge date date of birth sex m service surgery allergies no known allergies adverse drug reactions attending chief complaint chronic abdominal pain and severe stenosis of the origin of the celiac artery as well as the sma major surgical or invasive procedure superior mesenteric artery angioplasty and stent via left groin access history of present illness is a man with a history of chronic abdominal pain weight loss and the finding on mra of a very severe stenosis of the origin of the celiac artery as well as the sma he was therefore offered visceral angiogram with possible intervention of note his mra also revealed chronic occlusion of his right iliac artery so access will be obtained via the left common femoral risks benefits and alternatives to this course of treatment were explained to the patient in detail and he consented to proceed past medical history past surgical history remarkable for back surgery and ankle surgery social history family history remarkable for patient s father having died of gastric cancer at the patient s mother died of natural causes at physical exam vital signs temp bp hr rr sat general well appearing well nourished in no distress abdomen nontender non distended abdomen flat no audible bruit in the epigastrium there is no mass extremities no evidence of cyanosis edema or varicosities neurologic intact alert and oriented x brief hospital course mr arrived to for admission on same day of his planned procedure of visceral angiogram with possible intervention upon arrival mr was placed npo for his procedure and all of his home medications were ordered mr was placed under moderate conscious sedation a realtime ultrasound guided access to the left common femoral artery and placement of a tourguide sheath was performed normal caliber visceral segment of the aorta with severe stenosis at the origin of the sma and celiac arteries was seen consistent with recent mra identified stenosis patient underwent angioplasty and stunting of the origin of the superior mesenteric artery the patient tolerated the procedure well pressure was held at the left groin for minutes with excellent hemostasis and signals were noted throughout in both feet bilaterally at the end of the procedure the patient was then observed with serial examinations until the return of his pre sedation mental status and then was taken to the pacu for further recovery patient was taken to the floor and monitored for abdominal pain and bleeding from his groin next day on the patient was advanced to regular diet and multiple abdominal exams were performed the patient tolerated diet well and complained of no abdominal pain the patient was stable and cleared from his vascular surgery and was discharged home to continue his recovery discharge medications acetaminophen mg po q6h prn pain severe clopidogrel mg po daily rx clopidogrel mg tablet s by mouth once a day disp tablet refills aspirin mg po daily rx aspirin enteric coated aspirin mg tablet s by mouth once a day disp tablet refills lisinopril mg po daily omeprazole mg po bid simvastatin mg po qpm discharge disposition home discharge diagnosis chronic mesenteric ischemia with severe celiac and superior mesenteric artery stenosis status post superior mesenteric artery angioplasty and stent discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear you were admitted to and underwent a superior mesenteric artery angioplasty and stent placement you have now recovered from surgery and are ready to be discharged please follow the instructions below to continue your recovery medication take aspirin 81mg once daily take plavix clopidogrel 75mg once daily continue all other medications you were taking before surgery unless otherwise directed you make take tylenol or prescribed pain medications for any post procedure pain or discomfort what to expect it is normal to feel tired and have a decreased appetite your appetite will return with time drink plenty of fluids and eat small frequent meals it is important to eat nutritious food options high fiber lean meats vegetables fruits low fat low cholesterol to maintain your strength and assist in wound healing to avoid constipation eat a high fiber diet and use stool softener while taking pain medication activities when you go home you may walk and use stairs you may shower let the soapy water run over groin incision rinse and pat dry your incision may be left uncovered unless you have small amounts of drainage from the wound then place a dry dressing or band aid over the area no heavy lifting pushing or pulling greater than lbs for week to allow groin puncture to heal after week you may resume sexual activity after week gradually increase your activities and distance walked as you can tolerate no driving until you are no longer taking pain medications call the office for numbness coldness or pain in lower extremities abdominal pain temperature greater than 5f for hours new or increased drainage from incision or white yellow or green drainage from incisions bleeding from groin puncture site sudden severe bleeding or swelling groin puncture site lie down keep leg straight and have someone apply firm pressure to area for minutes if bleeding stops call vascular office if bleeding does not stop call for transfer to closest emergency room followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies influenza virus vaccines latex attending chief complaint facial droop facial weakness major surgical or invasive procedure none history of present illness is a female with a pmhx of laryngeal cancer s p resection and radiation with r temporal lesion thought to be due to radiation necrosis followed by dr episodes of r facial pain chronic daily ha and episodes of panic confusion and r hemibody numbness szs per dr and pnes who presents with r facial droop and r sided weakness lasting approximately minutes by the time of evaluation these symptoms had resolved her nchct did not reveal any evidence of stroke and her vessels were patent on cta h n revealing only her prior carotid stent as well as some basilar narrowing seen on prior imaging the latter may be due to radion vasculopathy her nihss was could not name cactus neglected left hemibody her symptoms localize to a l mca distribution of note she was recently admitted to neurology for episodes of bilateral weakness dysarthria out of body sensation vertigo and headache she was evaluated by eeg and her episodes did not have an eeg correlate and were thought to be due to panic attacks given that headache occurred after symptoms migraine with aura less likely seizure less likely given prolonged event and recent work up panic attcks as well as pnes however are diagnoses of exclusion and she will need a tia work up of note she had a recent admission to the neurology services where she had long term eeg eval which showed no seizure activity and likely panic attacks she was discahgred with neurology and psychiatry followup of note primary concern at moment is tia r o before assuming above episodes is pnes she is being admitted to medicine service for concern of hypokalemia and hyponatremia likely due to viral gastroenteritis her ct abd pelvis in ed was wnl and lactate wnl in the ed initial vital signs were ra labs were notable for negative u a negative blood culture wnl cbc cr from na from imaging ct abd pelvis no acute findings in the abdomen or pelvis small volume free pelvic fluid of unclear etiology unchanged since the prior exam the patient was given l ns consults neurology felt needs workup for tia medicine admit given cr from vitals prior to transfer were ra upon arrival to the floor i spoke with patient and her daughter daughter reports that after eating soup with cheese yesterday patient had significant nausea and vomiting no fevers or chills no dysuria no sob mild headaches she reports that it was tonight for her to keep anything down since ingesting soup yesterday daughter reports at at around last night for about minutes patient become acutely somnolent and then couldn t remember where they were en route to hospital and that she had a right facial droop and right arm numbness she reports she was bringing her mom in given concern for elevated blood pressure the past day sys up to s past medical history cva mi anemia appendectomy back pain right sciatica cataracts hypertension hypothyroidism s p thyroidectomy years ago now on levothyroxine right ankle surg pins throat cancer followed at throat cancer surgery thyroidectomy tobacco abuse tonsilectomy stenosis r carotid artery device placed and removed brain tumor adenoid cystic carcinoma depression dyspnea on exertion recheck chest ct seasonal affective d o admitted to for dizziness thought to be secondary to benign paroxysmal positional vertigo also thought that symptoms exacerbated by stress due to verbal abuse experienced at home from her son admission for pnes social history family history strong family history of malignancy one brother deceased in his with liver malignancy another in his with lung cancer mother deceased reportedly at in the setting of multiple medical problems plus a stroke her father died at patient denies other neurologic family history other than the above physical exam on admission vitals t hr bp rr ra general pleasant well appearing occasionally dry heaving heent normocephalic atraumatic neck supple no lad no thyromegaly jvp flat cardiac rrr normal s1 s2 no murmurs rubs or gallops pulmonary clear to auscultation bilaterally over anterior and axillary chest abdomen normal bowel sounds soft non tender non distended no organomegaly extremities warm well perfused no cyanosis clubbing or edema skin without rash neurologic cnii xii grossly intact moves all extremeities sponatenously str plantarflex dorsiflex can squeeze fingers b l on discharge vitals t bp hr rr spo2 on ra general pleasant well appearing heent normocephalic atraumatic neck supple no lad no thyromegaly jvp flat cardiac rrr normal s1 s2 no murmurs rubs or gallops pulmonary clear to auscultation bilaterally over anterior and axillary chest abdomen normal bowel sounds soft non tender non distended no organomegaly extremities warm well perfused no cyanosis clubbing or edema skin without rash neurologic cnii xii grossly intact moves all extremities spontaneously gait slowed but normal pertinent results admission labs 20pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 20pm blood glucose urean creat na k cl hco3 angap 20pm blood albumin calcium phos mg cholest 13am blood calcium phos mg 20pm blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg 34pm blood lactate microbiology final report urine culture final mixed bacterial flora colony types consistent with skin and or genital contamination pm blood culture blood culture routine pending imaging studies cta head neck wwo contrast impression extensive confluent white matter disease likely secondary to combination of posttreatment changes and chronic microvascular ischemic disease which limits evaluation for acute infarct geographic hypodensity in the right subcortical temporal lobe is consistent with previously seen vasogenic edema recommend correlation with prior mri from no evidence for acute intracranial hemorrhage patent right common carotid internal carotid artery stent stable short segment focal high grade stenosis of the mid basilar artery stable right upper lobe lung nodules since cxr pa lat impression no acute cardiopulmonary abnormality eeg impression this is an abnormal routine eeg in the awake and drowsy states due to the presence of frequent bursts of generalized delta frequency slowing as well as occasional bursts of right frontotemporal focal delta frequency slowing during wakefulness these findings are consistent with deep midline brain dysfunction and an additional independent focus of subcortical dysfunction in the right frontotemporal region the background is mildly disorganized suggesting a mild diffuse encephalopathy there are no epileptiform discharges or electrographic seizures in this recording ct abd pelv wo contrast impression no acute findings in the abdomen or pelvis small volume free pelvic fluid of unclear etiology unchanged since the prior exam fibroid uterus tte conclusions the left atrial volume index is normal 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 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 no aortic stenosis is pesent no aortic regurgitation is seen the mitral valve leaflets are mildly thickened mild to moderate mitral regurgitation is seen due to acoustic shadowing the severity of mitral regurgitation may be significantly underestimated the estimated pulmonary artery systolic pressure is normal there is no pericardial effusion impression mild mitral leaflet and subvalvular apparatus thickening with mild moderate mitral regurgitation normal biventricular cavity sizes with preserved regional and global biventricular systolic function increased pcwp no definite structural cardiac source of embolism identified clinical implications based on aha endocarditis prophylaxis recommendations the echo findings indicate prophylaxis is not recommended clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data mr head wo contrast impression small acute infarctions in the pons and posterior superior right cerebellar hemisphere no evidence of hemorrhage edema or mass effect extensive stable matter signal abnormality likely combination of posttreatment changes and chronic microvascular ischemic disease stable subcortical white matter disease in the right temporal lobe previously seen contrast enhancing lesion in the right temporal lobe is similar in size to prior examination measuring approximately cm in greatest dimension however incompletely characterized given lack of contrast administration on the current examination discharge labs 56am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 56am blood calcium phos mg 56am blood glucose urean creat na k cl hco3 angap female with a pmhx of laryngeal cancer s p resection and radiation with r temporal lesion thought to be due to radiation necrosis followed by dr episodes of r facial pain chronic daily ha and episodes of panic confusion and r hemibody numbness szs per dr and pnes who came into ed with nausea vomiting and right sided numbness largely negative workup except for orthostatic hypotension then found to have small cerebellar and pontine infarcts on mri cerebellar pontine stroke per mri very small infarcts in this region likely due to decreased perfusion in the setting of gastroenteritis and very narrow basilar artery she did not appear to have consequential gross neurologic deficits during this admission her 20min eeg was not concerning her transient facial droop and numbness does not correspond to the location of the lesion and reportedly occurred in the past though to be possibly related to her pnes per dr she does have hyperlipidemia with ldl so clopidogrel and atorvastatin 80mg daily were started for secondary prevention start dual antiplatelet therapy add clopidogrel to current aspirin therapy she will follow up with her current neurologist dr have home viral gastroenteritis orthostatic hypotension pt reported nausea vomiting prior to admission and had positive orthostatic vital signs in the ed she also has had poor po intake chronically her gi symptoms improved during the admission she was started on nutrition supplements and given iv fluids with good response she worked with on day of discharge without symptoms her antihypertensives were held at discharge sbps were 150s at discharge she was encouraged to take po and nutritional supplements hypothyroidism tsh was at admission given her altered mental status and orthostatic hypotension her home levothyroxine was increased from 50mcg to 75mcg daily chronic issues hypertension her home antihypertensives were held in the setting of orthostatic hypotension pnes topamax and lorazepam were initially held given her altered mental status topamax was restarted but lorazepam was held to prevent further episodes of confusion after discussion with family and outpatient neurologist depression she was continued on sertraline transitional issues patient should work with home given deconditioning from her acute illness and acute stroke please recheck tsh in weeks and adjust levothyroxine dose as necessary home lorazepam was held given her altered mental status and after discussion with outpatient neurologist dr orthostatic hypotension antihypertensives were held at discharge her supine sbps were 150s at discharge please check orthostatic vital signs at home and pcp followup and consider restarting if hypertensive per family patient has had gradual decline in cognitive function and hearing please discuss at pcp appointment whether hearing aids would be appropriate medications on admission the preadmission medication list is accurate and complete aspirin mg po daily atenolol mg po daily chlorthalidone mg po daily fish oil omega mg po daily levothyroxine sodium mcg po daily lisinopril mg po daily topiramate topamax mg po bid lorazepam mg po bid sertraline mg po daily loratadine mg po daily discharge medications aspirin mg po daily fish oil omega mg po daily levothyroxine sodium mcg po daily rx levothyroxine mcg tablet s by mouth daily disp tablet refills sertraline mg po daily topiramate topamax mg po bid atorvastatin mg po qpm rx atorvastatin mg tablet s by mouth daily disp tablet refills clopidogrel mg po daily rx clopidogrel mg tablet s by mouth daily disp tablet refills loratadine mg po daily discharge disposition home with service facility discharge diagnosis primary acute cerebellar and pontine cva viral gastroenteritis presyncopal event due to hypovolemia secondary orthostatic hypotension hypothyroidism pnes hypertension discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear ms you came to the hospital because you had nausea vomiting and felt numb on your right side at the hospital you were evaluated by our medicine doctors and our our neurologists determined that you had a very small stroke in your cerebellum and pons and our medicine doctors determined might have fainted because of volume loss from a stomach bug we are discharging you home with physical therapy services so you can get stronger we ask that you follow up with your neurologist and primary care doctor as below we wish you all the best your care team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies influenza virus vaccines latex atorvastatin ativan clopidogrel lisinopril chlorthalidone attending chief complaint headache htn major surgical or invasive procedure none history of present illness with a pmh of cva tia hld htn laryngeal cancer brain lesion likely radiation necrosis carotid stenosis s p stents who presents for eval of headache and elevated bp the patient endorses gradual onset right frontal headache with is throbbing in nature she also endorses intermittent dizziness like the room is spinning nausea and decreased po intake she recently restarted her home atenolol with which she has been noncompliant for months due to insurance reasons and only restarted days ago she says she has stopped lisinopril due to cough has a history of prior similar headaches no focal weakness no chest pain or sob denies ever getting ha with high bp s before checked her bp yesterday and it was at called pcp office who instructed her to come in in the ed initial vitals were hr rr ra bp subsequently peaked at received 10mg iv labetalol and down to s then received 100mg po labetalol and down to later labs showed negative trop normal ua cbc chem and coags imaging showed cta head and neck without intracranial hemorrhage old infarcts and known temporal mass noted new mm aneurysm left vertebral artery no flow limiting stenosis received tylenol 2l ns in addition to the bp meds above neuro was consulted recommending bp control mri and medicine admission on arrival to the floor her ha was much improved now very little review of systems per hpi point ros reviewed and negative unless stated above in hpi past medical history laryngeal cancer cva tia hypertension hld hypothyroidism after thyroid surgery for nodule stenosis status post right carotid stents cervical cancer hysterectomy tonsilectomy appendectomy right ankle fracture pins placed bilateral cataracts social history family history she had two brothers one died in his with liver cancer and one died in his with lung cancer multiple elder family members developed severe vision loss physical exam admission physical exam vital signs hr rr ra general alert oriented no acute distress heent sclerae anicteric mmm oropharynx clear eomi perrl neck supple but ttp on right side chronic 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 ext warm well perfused pulses no clubbing cyanosis or edema neuro cnii xii intact strength in all extremities no pronator drift discharge physical exam vital signs ra general alert oriented no acute distress heent sclerae anicteric mmm oropharynx clear eomi perrl 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 ext warm well perfused pulses no clubbing cyanosis or edema neuro cniii xii intact though pt reports blurry vision strength in all extremities no pronator drift pertinent results admission labs 40pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 40pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 40pm blood ptt 40pm blood glucose urean creat na k cl hco3 angap 40pm blood ctropnt 40pm blood calcium phos mg 55pm urine color straw appear clear sp 55pm urine blood neg nitrite neg protein neg glucose neg ketone neg bilirub neg urobiln neg ph leuks neg micro urine urine culture final report urine culture final mixed bacterial flora colony types consistent with skin and or genital contamination studies cta head and neck no evidence of intracranial hemorrhage or large territorial infarction a right temporal lobe lesion identified on prior mri is not appreciated adjacent white matter hypoattenuation is unchanged lacunar infarcts involving the left basal ganglia and left pons are again noted confluent periventricular and subcortical white matter hypoattenuation is unchanged there is a new mm aneurysm involving the v2 segment of the left vertebral artery series image a right common carotid artery stent is widely patent there are dense atherosclerotic calcifications at the bifurcation of the left common carotid artery without evidence of flow limiting stenosis the remaining major arteries of the neck are patent without evidence of flow limiting stenosis dissection or aneurysm formation cxr no acute cardiopulmonary abnormality mri w and w o contrast unchanged right temporal extra axial lesion with unchanged surrounding edema no acute infarcts mass effect or hydrocephalus no new enhancing lesions superficial siderosis within the right temporal parietal sulcus better visualized on the current study discharge labs 16am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 16am blood glucose urean creat na k cl hco3 angap 16am blood calcium phos mg y o f with a history of cva tia hld htn laryngeal cancer brain lesion thought to be radiation necrosis carotid stenosis s p stents who presents for fatigue headache and elevated bp in setting of prolonged medication non use secondary to insurance issues initial concern for hypertensive emergency no other organ systems though also concern for temporal brain lesion as etiology she was seen by neuro oncology who felt that brain lesion was not the culprit to explain her symptoms given stability on serial mri blood pressure was controlled with new regimen of losartan and carvedilol with good response tsh was elevated to give recent medication non use levothyroxine was resumed notably her headaches correlated with the times when she was quite hypertensive sbp and resolved with improved bp control making hypertensive emergency a more likely unifying diagnosis headache hypertensive emergency presents with headache poorly controlled bp and recent med nonadherence due to insurance issues with presentation concerning for hypertensive emergency sbp peaked in s and dbp peaked in s at cta head without any bleed or acute process though does show old lacunar infarcts and left common carotid artery calcifications seen by neuro in ed who felt this mostly represents hypertensive emergency did not recommend neuro admission but did recommend mri brain ua cxr ekg and labs reassuring notably her headaches correlated with the times when she was quite hypertensive sbp and resolved with improved bp control making hypertensive emergency a more likely unifying diagnosis mri brain stable from prior and seen by neuro oncology who felt that her symptoms were better explained by her htn she was started on carvedilol and amlodipine with good response temporal lobe lesion thought to be probably radiation necrosis rather than malignancy given the stability on serial imaging though neurology consult with concern for neoplastic process case was discussed in neuro oncology who felt given stable imaging that her bp should be controlled and she could cont to follow up as an outpatient h o cva tia carotid stenosis no evidence of stroke of cva on admission cta or mri she was stared on aspirin postsurgical hypothyroidism tsh elevated to on admission though likely in the setting of not able to afford medications continued home levothyroxine transitional code full contact hcp daughter alternative home work recheck tsh as outpatient in weeks titrate levothyroxine accordingly recommend ongoing titration of blood pressure medications aspirin started while inpatient given history of cvas pt will have ophthalmology followup on discharge as blurry vision contributing to headaches pt should have repeat serum chemistry evaluation given initiation of losartan close to hospital discharge medications on admission the preadmission medication list may be inaccurate and requires futher investigation albuterol inhaler puff ih q4h prn sob atenolol mg po daily levothyroxine sodium mcg po daily sertraline mg po daily topiramate topamax mg po daily discharge medications acetaminophen mg po q6h aspirin mg po daily rx aspirin 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 losartan potassium mg po daily rx losartan mg tablet s by mouth twice a day disp tablet refills rx losartan mg tablet s by mouth daily disp tablet refills levothyroxine sodium mcg po daily rx levothyroxine mcg tablet s by mouth daily disp tablet refills albuterol inhaler puff ih q4h prn sob topiramate topamax mg po daily discharge disposition home discharge diagnosis primary hypertensive urgency headache secondary temporal lobe lesion 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 meeting you and taking care of you you were admitted to for evaluation of fatigue and headache you were found to have very high blood pressure which improved with some some new medications we also saw that your thyroid levels were really low and likely causing your fatigue this should improve with resuming your home levothyroxine we wish you the best your team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies influenza virus vaccines latex atorvastatin ativan clopidogrel lisinopril chlorthalidone attending chief complaint headache major surgical or invasive procedure n a history of present illness yo female with a history of laryngeal cancer and a right temporal mass who is admitted with headaches and hypertensive urgency the patient states she has been having intermittent headaches weakness nausea and vision changes for three days she denies any fevers shortness of breath diarrhea constipation dysuria or rashes she states she is taking carvedilol twice a day and atenolol once a day for her blood pressure she reports not taking losartan she does seem confused about her medications and per report her daughter also is concern about her management of medications at home she reportedly lives with her son who is bipolar and causes he significant stress she presented to the ed on and was found to be hyptertensive a head ct was done and unchanged from prior and she was sent home in the ed this evening she was again found to be hypertensive to 200s 100s she was given carvedilol with improvement in her blood pressure on arrival to the floor she states that her headache and other symptoms have significantly improved past medical history laryngeal cancer cva tia hypertension hld hypothyroidism after thyroid surgery for nodule stenosis status post right carotid stents cervical cancer hysterectomy tonsilectomy appendectomy right ankle fracture pins placed bilateral cataracts social history family history she had two brothers one died in his with liver cancer and one died in his with lung cancer multiple elder family members developed severe vision loss physical exam admission exam general nad vital signs t bp hr rr o2 ra heent mmm no op lesions cv rr nl s1s2 pulm ctab abd soft ntnd no masses or hepatosplenomegaly limbs no edema clubbing tremors or asterixis skin no rashes or skin breakdown neuro alert and oriented no focal deficits cranial nerves ii xii are within normal limits excluding visual acuity which was not assessed strength is of the proximal and distal upper and lower extremities discharge exam vital signs t bp hr rr o2 ra general pleasant animated woman sitting up comfortably in bed heent mmm no nystagmus perll eomi op clear cv rr nl s1s2 no s3s4 no mrg pulm ctab respirations unlabored abd bs soft ntnd limbs no edema normal bulk wwp skin no rashes on extremities neuro alert and interactive oriented x3 no focal weakness including symmetric upper extremity strength and lower extremity strength ftn intact cn iii xii intact pertinent results admission labs 40pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 40pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 40pm blood plt 40pm blood glucose urean creat na k cl hco3 angap 44am blood alt ast ld ldh alkphos totbili 40pm blood calcium phos mg 15pm blood crp discharge labs 44am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 18am blood glucose urean creat na k cl hco3 angap 18am blood calcium phos mg imaging imaging mrv head w o contrast no evidence of cerebral venous thrombosis unchanged x mm enhancing right middle cranial fossa extra axial lesion previously noted subtle area of right medial occipital leptomeningeal enhancement is not well appreciated on the current examination likely due to difference in technique no new enhancing lesion multiple chronic infarcts as described confluent areas of white matter signal abnormality in a configuration most suggestive of chronic small vessel ischemic disease imaging mr head w w o contras new small evolving acute or early subacute infarct within the left posterior inferior cerebellar hemisphere stable enhancing extraaxial mass along the medial right temporal lobe stable small area of leptomeningeal enhancement along the medial right occipital lobe dating back to etiology uncertain stable chronic infarctions within bilateral cerebellar hemispheres and left pons stable extensive confluent white matter changes in right greater than left temporal white matter and bilateral frontal and parietal white matter as well as in the middle cerebellar peduncles and bilateral pons likely a combination of posttreatment changes and sequela of chronic small vessel ischemic disease stable left frontal developmental venous anomaly brief hospital course principle reason for admission w cad tia htn dl brainstem cva h o submandibular cystic carcinoma diagnosed in followed by modified radical neck dissection r temporal mass most likely xrt necrosis stable since carotid stenosis s p stents and history of hypertensive emergency causing headaches due to medication noncompliance p w ha dizziness and nausea found to have hypertensive emergency and new cerebellar cva now with persistent intractable headache hypertensive emergency hypertension etiology of hypertensive emergency thought due to noncompliance of her home medications and she improved with resumption of home carvedilol and losartan however her headache persisted and after staring iv dexamethasone her blood pressures again worsened we uptitrated her carvedilol to 25mg bid and increased losartan to 100mg daily she continued to require intermittent po labetolol and iv hydralazine on we restarted her on chlorthalidone 25mg daily she had previously taken this but was stopped due to urinary frequency day of discharge blood pressure was better controlled in the s s she was discharged with these medications and po potassium meq daily she should have blood pressure and chemistry panel checked on consider investigating secondary causes of hypertension at her primary team s discretion stroke etiology thought from htn disease hours of telemetry were unremarkable and prior carotid imaging was normal last ldl was last a1c no clear focal neurologic deficits despite new cva on imaging patient was previously on asa and plavix but she discontinued plavix due to dizziness some time ago unclear if she was taking asa at home we restarted plavix statin was held given patient s reported statin allergy although this should continually be discussed with her pcp persistent l sided ha status migranosis etiology of headache initially thought due to uncontrolled htn however headaches persisted despite better bp head mri revealed small cerebellar ischemic stroke as above which was out of proportion to her headaches mrv was negative for venous thrombosis crp esr not indicative of temporal arteritis deferred lp given no suspicion for infection she was initially treated with fioricet and tramadol received small amounts of iv morphine ulitmately opiods and tramadol limited due to concern for rebound headache overuse headache she was given days of iv dexamethasone starting and started acetazolamide 500mg twice daily on headache broke on evening of and patient was discharged pain free she will continue acetazolamide indefinitely per her neuro oncologist dr should follow up with him in weeks metabolic acidosis patient developed non gap hyperchloremic metabolic acidosis likely due to acetazolamide will continue acetazolamide and continue to monitor hypothyroidism continued home synthroid last tsh rechecked tsh here and gerd continued home omeprazole social on admission there was some concern regarding patient s safety at home sw was consulted and safe discharge plan was developed ultimately felt to be safe for home discharge in light of her extensive support system and ability to call should there be an emergency this plan was made in accordance to the patient s wishes as well please see sw noted for further information billing minutes spent planning and executing this discharge plan transitional issues close monitoring of blood pressures and medication compliance increased losartan to 100mg daily and carvedilol to 25mg twice daily started chlorthalidone 25mg daily on and discharged with 10meq potassium supplements please recheck chemistry on resumed plavix currently holding aspirin discuss statin use with patient given recurrence cerebrovascular disease medications on admission the preadmission medication list is accurate and complete albuterol inhaler puff ih q4h prn sob levothyroxine sodium mcg po daily topiramate topamax mg po daily acetaminophen mg po q6h prn pain mild aspirin mg po daily carvedilol mg po bid atenolol dose is unknown po daily omeprazole mg po daily losartan potassium mg po daily discharge medications acetazolamide mg po q12h rx acetazolamide mg capsule s by mouth twice a day disp capsule refills chlorthalidone mg po daily rx chlorthalidone mg tablet s by mouth daily disp tablet refills clopidogrel mg po daily rx clopidogrel mg tablet s by mouth daily disp tablet refills potassium chloride meq po daily hold for k rx potassium chloride klor con meq 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 losartan potassium mg po daily rx losartan mg tablet s by mouth daily disp tablet refills acetaminophen mg po q6h prn pain mild rx acetaminophen mg tablet s by mouth q6 hours disp tablet refills albuterol inhaler puff ih q4h prn sob rx albuterol sulfate proair hfa mcg puff ih q4 hours disp inhaler refills levothyroxine sodium mcg po daily rx levothyroxine mcg tablet s by mouth daily disp tablet refills omeprazole mg po daily rx omeprazole mg capsule s by mouth daily disp capsule refills topiramate topamax mg po daily rx topiramate topamax mg tablet s by mouth daily disp tablet refills discharge disposition home with service facility discharge diagnosis cva hypertensive emergency status migraine discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear ms it was a pleasure taking care of you at you were admitted for severe headaches you were found to have a hypertensive emergency and your blood pressures improved with restarting your home carvedilol and losartan we ultimately increased your carvedilol and losartan doses and started an new medication called chlorthalidone you cannot miss these medications and you must follow up with dr very close monitoring of your blood pressure and blood work additionally had a brain mri which revealed a small stroke you continued to have very severe headaches so we gave you a three day course of iv dexamethasone steroids and started a medication called acetazolamide you will need to follow up with drs sincerely your care team followup instructions

name unit no admission date discharge date date of birth sex f service neurology allergies influenza virus vaccines latex atorvastatin ativan lisinopril chlorthalidone attending chief complaint headache and dizziness major surgical or invasive procedure none history of present illness ms is a yo woman with history of laryngeal cancer and l temporal lesion as well as history of multiple lacunar infarcts and microvascular disease as well as recent admission for hypertensive emergency and headache during which she was found to have small l cerebellar infarct who presents to the ed with headache and dizziness ms was recently admitted from through to the medicine service after presenting with hypertensive emergency course complicated by status migrainosus which resolved after days of iv dexamethasone and for which she was started on acetazolamide course also complicated by incidental tiny left cerebellar infarct thought by medicine team to be likely related to hypertension this was treated as an aspirin failure and she was switched to plavix she is not on a statin due to reported statin allergy during admission she was evaluated by her outpatient neuro oncologist dr at that time neurologic exam is documented as normal except brisk but symmetric reflexes as well as moderate ataxia and aphasia with ambulation ms reports that her headache had resolved after discharge but returned this afternoon the headache started at the vertex at approx and became severe by and also spread to the r hemicranium the headache is sharp in character associated with photophobia and nausea no phonophobia no emesis she states that she has had headaches like this in the past though they all started after age she also describes dizziness that started around the same time as the headache she has great difficulty describing the dizziness but states it was episodic lasting seconds at a time and is best described as vertigo when given choices she says that the last time she had the vertigo was when i was upstairs in a bed like this one she is unable to provide an answer when asked if there are any provoking factors she also reports chest pain and states she did not tell the emergency room doctors because she did not want to stay overnight unable to complete ros due to mental status past medical history right submandibular cystic carcinoma diagnosed in treated with modified radical neck dissection and radiation hypertension hypothyroidism anemia right ica stenosis status post right carotid stenting cervical cancer status post hysterectomy tonsillectomy appendectomy dyslipidemia pontine lacune bilateral cataracts social history family history she had two brothers one died in his with liver cancer and one died in his with lung cancer multiple elder family members developed severe vision loss physical exam admission physical exam general sleepy lying in bed covered up in multiple blankets intermittently appears to be in pain stated secondary to chest discomfort heent no scleral icterus dry mm no oropharyngeal lesions pulmonary breathing comfortably no tachypnea nor increased wob cardiac skin warm well perfused tenderness to palpation at right costochondral junction abdomen soft nd extremities symmetric no edema neurologic examination mental status sleepy keeps eyes closed during most of the examination opening only when necessary requires repeated stimulation to participate in exam oriented to hospital but not which states date is though i needed to ask her the year month and date multiple times each because she kept replying difficulty providing history provides few details answers to direct questions are at times tangential or absent states she is still working even though prior records indicate that she has retired attention severely impaired unable to name days of week forward nor repeat a forward digit span of anomia to low frequency words though interpretation is limited by the fact that is her second language repetition intact comprehension intact to simple but not complex commands perseverative cranial nerves perrl eomi without nystagmus facial sensation intact to light touch face symmetric at rest and with activation hearing intact to conversation palate elevates symmetrically strength in trapezii bilaterally tongue protrudes in midline motor normal bulk increased tone bilateral lower extremities keeps arms outstretched for pronator drift testing only momentarily during which bilateral pronation without downward drift is noted before putting her arms down despite coaching patient has significant difficulty participating in the confrontational motor testing but gives at least some resistance in all muscle groups and the resistance reaches full strength for the first muscle groups tested delt bic tri and then patient has progressive difficulty cooperating with exam and symmetric range effort is noted throughout the remainder of the exam dtrs bi tri pat ach pec jerk crossed abductors l r plantar response was obscured by marked withdrawal bilaterally sensory intact to lt temperature throughout unable to participate in vibration or proprioceptive testing coordination subtle dysmetria with left finger to nose testing gait patient refuses discharge physical exam neurologic mental status alert and oriented x3 attention states dowb without difficulty memory recall with mcq cue speech normal rate rhythm volume comprehension and naming intact able to follow complex commands cranial nerves i not tested ii left lower quadrantopia on visual field examination iii iv vi eomi without nystagmus perrl no ptosis v sensation intact to light touch vii no facial musculature asymmetry viii hearing diminished but equal bilaterally ix x palate elevates symmetrically xi strength in trapezii and scm bilaterally motor normal bulk and tone no pronator drift c5 c5 c7 c6 c7 t1 l2 l3 l5 l4 s1 l5 l r dtrs bi tri pat ach l r plantar response showed withdrawal b l sensory intact to lt throughout coordination subtle dysmetria with left finger to nose testing gait deferred pertinent results 45am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 40pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 10am blood ptt 45am blood glucose urean creat na k cl hco3 angap 40pm blood glucose urean creat na k cl hco3 angap 40pm blood alt ast alkphos totbili 00pm blood ctropnt 45am blood calcium phos mg 40pm blood albumin calcium phos mg 02am blood hba1c eag 02am blood triglyc hdl chol hd ldlcalc 40pm blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg cta h n notable finding atherosclerotic vascular calcifications resulting in mild to moderate luminal narrowing of the petrous segment of the right ica similar to the prior study moderate luminal narrowing of the proximal to mid basilar artery again seen likely atherosclerotic mri head w o contrast acute to subacute infarction is seen involving the right parieto occipital lobe left parietal lobe and right cerebellum possible punctate focus of infarction is seen within the left cerebellum distribution appears to be embolic in etiology stable extensive confluent white matter changes right greater than left temporal white matter bilateral frontoparietal white matter as well as middle cerebellar peduncles likely combination of posttreatment changes and sequelae of chronic small vessel ischemic disease brief hospital course ms is a year old woman with pmh hypertension carotid stenosis s p r ica stent multiple prior strokes cad c b mi laryngeal cancer s p surgery and radiation therapy who was admitted to neurology stroke service with headache and dizziness she was evaluated on telemetry and started on aspirin therapy she was seen to have elevated ldl and due to previous statin intolerance was started on zetia she was seen on mri to have ischemic stroke in the right parieto occiptal lobe left parietal lobe and left cerebellar lobe as well as moderate narrowing of basilar artery these findings were suggestive of thrombotic etiology of her stroke she underwent echocardiogram without concern she was started on dual anti platelet therapy with aspirin and plavix her deficits left visual field impairment dysmetria improved prior to discharge she was discharged home with outpatient and services transition issues pt will need to continue taking aspirin and plavix for secondary stroke prevention pt will need to continue taking zetia for hyperlipidemia will f u pt s echocardiogram final results if anything concerning that is pertinent to patient s recent stroke will contact pt to inform pt will need to f u with pcp and on admission albuterol sulfate ventolin hfa ventolin hfa mcg actuation aerosol inhaler puffs s inhaled every four hours as needed for cough wheeze chest congestion short of breath mdi with dose counter carvedilol carvedilol mg tablet tablet s by mouth twice daily dc med rec levothyroxine levothyroxine mcg tablet tablet s by mouth once a day dc med rec losartan losartan mg tablet tablet s by mouth daily dc med rec omeprazole omeprazole mg capsule delayed release capsule s by mouth qday sertraline sertraline mg tablet tablet s by mouth prescribed by other provider per pt in therapist f u so end w plan for md not taking as prescribed last filled in topiramate topiramate mg tablet tablet s by mouth twice a day prescribed by other provider triamcinolone acetonide triamcinolone acetonide topical cream apply to rash hands three times a day medications otc aspirin aspirin mg tablet delayed release tablet s by mouth daily admission med rec discharge medications aspirin mg po daily rx aspirin mg tablet s by mouth daily disp tablet refills ezetimibe mg po daily rx ezetimibe mg tablet s by mouth daily disp tablet refills albuterol inhaler puff ih q6h prn sob carvedilol mg po bid clopidogrel mg po daily rx clopidogrel mg tablet s by mouth dao u disp tablet refills levothyroxine sodium mcg po daily omeprazole mg po daily topiramate topamax mg po daily discharge disposition home with service facility discharge diagnosis stroke discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms you were hospitalized due to symptoms of headache and dizziness resulting from an acute ischemic stroke a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot the brain is the part of your body that controls and directs all the other parts of your body so damage to the brain from being deprived of its blood supply can result in a variety of symptoms stroke can have many different causes so we assessed you for medical conditions that might raise your risk of having stroke in order to prevent future strokes we plan to modify those risk factors your risk factors are high blood pressure high cholesterol we are changing your medications as follows aspirin mg daily for stroke prevention clopidegrel plavix 75mg daily for stroke prevention ezetimibe zetia 10mg daily for cholesterol 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 medicine allergies influenza virus vaccines attending chief complaint headache dizziness nausea major surgical or invasive procedure there were no major surgical or invasive procedures during hospitalization history of present illness year who was sent in by on after experiencing headache and emesis the headache was acute in onset however no headstrike or injuries were reported she also developed bilateral lower extremity weakness requiring her to have to walk as she was unsteady on her feet there was concern regarding her presentation as she experienced similar symptoms when she had a prior stroke in the ed initial vitals were pain temperature hr bp rr pulse ox on ra urine serum toxicology screen was negative ua was negative chemistry panel was normal except for a bun of lft s were normal except for an alk phos of cbc was within normal limits she underwent a cta head and neck with preliminary reading showing no flow limiting stenosis in the intracranial and cervical vessels no evidence of aneurysm greater than mm or dissection patent stent graft in the right common carotid artery calcified and non calcified plaque at the left carotid bifurcation causing mild narrowing atherosclerotic calcification involving the left greater than right cervical vertebral arteries severe atherosclerotic disease of the aortic arch and descending aorta with both calcified and non calcified plaque unchanged mm right upper lobe pulmonary nodule follow up per prior chest ct s the patient was evaluated by neurology who suspected that the patient s current presentation was due to sub acute spinal pathology coupled with ongoing medical illness and stress due to home situation the patient was evaluated by in the ed who recommended visits or discharge to rehab the patient was admitted to medicine for coordination of care and symptomatic management on the floor the patient reports improvement in her nausea and abdominal pain she has some persistent left lower extremity weakness compared to right she reports intermittent dizziness which she describes as the sensation that the room is spinning around her she reports stress regarding her son and his issues with addiction which she has dealt with for some time she reported headache on presentation bi temporal which has improved the patient does not remember the exact events when she was walking to her closet yesterday morning but she did not experience any prodromal symptoms nor changes in vision past medical history cva mi anemia appendectomy back pain right sciatica cataracts hypertension hypothyroidism s p thyroidectomy years ago now on levothyroxine right ankle surg pins throat cancer followed at throat cancer surgery thyroidectomy tobacco abuse tonsilectomy stenosis r carotid artery device placed and removed brain tumor adenoid cystic carcinoma depression dyspnea on exertion recheck chest ct seasonal affective d o admitted to for dizziness thought to be secondary to benign paroxysmal positional vertigo also thought that symptoms exacerbated by stress due to verbal abuse experienced at home from her son social history family history strong family history of malignancy one brother deceased in his with liver malignancy another in his with lung cancer mother deceased reportedly at in the setting of multiple medical problems plus a stroke her father died at patient denies other neurologic family history other than the above physical exam admission physical exam vital signs on ra general alert oriented tearful when discussing son otherwise not in acute distress heent pale conjunctiva jvp not visualized hard post surgical post radiation changes in left submandibular area left cheek not tender to light palpation no oropharnygeal lesions visualized cv rrr nl s1 s2 no murmurs rubs gallops no carotid bruit b l lungs cta b l 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 edema neuro cnii xii intact though patient refuses to extend tongue for testing of cn12 strength upper lower extremities grossly normal sensation upgoing babinskin on left downgoing on right gait deferred negative b l mild left lateral end gaze nystagmus discharge physical exam vitals ra general aox3 lying in bed appears comfortable very pleasant heent mmm hard post surgical post radiation changes in left submandibular area left cheek not tender to light palpation cv rrr normal s1 and s2 no m r g lungs clear to auscultation bilaterally abdomen soft nt nd no rebound or guarding ext warm well perfused no edema neuro aox3 eomi cnii xii intact strength sensation 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 glucose urean creat na k cl hco3 angap 45pm blood albumin calcium phos mg 45pm blood alt ast alkphos totbili discharge labs 32am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 32am blood glucose urean creat na k cl hco3 angap 32am blood calcium phos mg serum toxicology 45pm blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg urine toxicology 00pm urine bnzodzp neg barbitr neg opiates neg cocaine neg amphetm neg oxycodn neg mthdone neg urine studies 00pm urine color straw appear clear sp 00pm urine blood neg nitrite neg protein neg glucose neg ketone neg bilirub neg urobiln neg ph leuks neg imaging cta head and cta neck impression extensive periventricular and subcortical white matter hypodensities relatively unchanged compared to the prior mri allowing for the differences in technique please note that evaluation for an underlying acute infarct is limited given the extensive hypodensities mri of the brain can be performed for further evaluation as clinically indicated vasogenic edema in the inferior right temporal lobe the previously known enhancing lesion in the right temporal lobe is not well visualized on the ct scan patent right internal and common carotid artery stent atherosclerosis involving the left carotid bifurcation without any stenosis by nascet criteria atherosclerosis involving v2 segment of left vertebral artery causing focal areas of mild luminal narrowing stable mm nodule in the right upper lobe further evaluation with dedicated ct of the chest can be performed as clinically indicated pelvis ap only findings no fracture or dislocation bilateral hip joint spaces are relatively well preserved with only minimal degenerative change pubic symphysis and si joints are preserved no radiopaque foreign body contrast is seen within the bladder impression no fracture or dislocation brief hospital course assessment and plan with pmh of htn hypothyroidism head and neck cancer s p neck dissection x2 who presented with complaints of vertigo and leg weakness after fall with complex social situation concerning for abuse vertigo secondary to bppv versus social stressors anxiety ms presented with nausea and dizziness based on description it appeared the vertigo appeared to be position in nature given her history of carotid stenosis a cta head and neck was obtained which did not show any evidence of new acute stroke neurology was consulted during hospitalization who did not believe symptoms could be explained by an acute stroke rather they believed the symptoms were consistent with benign paroxysmal positional vertigo as neurologic exam was completely benign during hospitalization it was also noted that ms symptoms occurred when she was talking about her stressful home situation a son at home who has a drug addiction and is verbally abusive to her when talking to her son on the phone ms would experience the dizziness and nausea she also experienced these symptoms when she described her stressful home situation to the medical team these symptoms would resolve after she had time to relax neurology did not believe any further work up was necessary as an inpatient and recommended follow up with her neurologist dr social stressors verbal abuse ms described her stressful home situation with her son she describes her son as addicted to crack she also described numerous episodes of verbal abuse to her she denied any physical abuse elder services had been involved in the past given this description social work was heavily involved during this hospitalization and initial mandated reporting was done upon admission she was hesitant to be discharged from the hospital until discharge plan was in place social work attempted to find other places for her to stay however patient elected to be discharged home to facilitate a safe discharge plan plans were made with police if any abuse at home plan would be contact police at precinct b2 with cell these plans were also communicated with patient s daughter to instruct on when to call the police prior to her discharge elder protective services were called for wellness and home safety evaluations to occur at home ms was able to voice back the safety plan that was developed and reported she felt comfortable with the safety plan attempts were made to locate safe housing prior to discharge but patient denied further services bacterial pneumonia patient recently diagnosed with atypical pneumonia at pcp started on course of levofloxacin she completed her day course of levofloxacin on she was not experience cough or fever and remained hemodynamically stable during hospitalization hypertension continued atenolol chlorthalidone and aspirin during hospitalization hypothyroidism continued levothyroxine during hospitalization transitional issues stable mm nodule in the right upper lobe further evaluation with dedicated ct of the chest can be performed as clinically indicated of note this lesion has been documented on previous ct scans of the chest cta head and neck marked atherosclerosis involving the aortic arch with penetrating atherosclerotic ulcer as seen on image further evaluation with dedicated ct of the chest can be performed as clinically indicated please continue to follow up with patient s safety situation at home if further concerns for elder abuse please contact elder services patient was noted to have mild leukopenia on labs please consider repeat cbc as outpatient and consider further evaluation code status dnr dni safety plan patient will be calling officer cell if there are any further safety issues medications on admission the preadmission medication list is accurate and complete atenolol mg po daily chlorthalidone mg po qam levofloxacin mg po q24h aspirin mg po daily levothyroxine sodium mcg po daily acetaminophen mg po q4h prn headache cold fish oil omega mg po daily discharge medications acetaminophen mg po q4h prn headache cold aspirin mg po daily atenolol mg po daily chlorthalidone mg po qam levothyroxine sodium mcg po daily fish oil omega mg po daily discharge disposition home discharge diagnosis primary diagnosis benign paroxysmal positional vertigo post traumatic stress disorder thought to be secondary to verbal abuse at home secondary diagnosis hypertension hypothyroidism prior cva throat cancer s p thyroidectomy depression 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 due to nausea and dizziness you were seen by the neurologists who recommended you undergo a ct scan of your head and neck this did not show evidence of a new stroke the dizziness you experienced seemed to be related to the movement of your head this is known as benign positional vertigo this usually resolves on its own we also noticed that your symptoms of nausea dizziness occurred when you were talking about your very stressful home situation stressors can make your symptoms worse to help find a safe place for you to be discharged to you were seen by social work their recommendations included a safety plan to contact the police if you feel unsafe at home your friend officer can be reached at cell and was contacted to ensure you have more safety checks at home further elder services were also contacted so that they can see you at home to ensure that it is a safe environment please follow up with your primary care physician and your specialists upon discharge from the hospital it was a pleasure taking care of your during your hospitalization we wish you all the best in the upcoming new year sincerely your care team followup instructions

name unit no admission date discharge date date of birth sex f service neurology allergies influenza virus vaccines attending chief complaint episodes of confusion dizziness subjective lower extremity weakness and out of body experience major surgical or invasive procedure none history of present illness hpi is a year old right handed woman with pmh significant for laryngeal cancer s p neck dissection and radiation therapy with a chronic stable right temporal brain lesion felt to be radiation necrosis who presents with multiple transient episodes of weakness dysarthria and headache the patient reports that the first of these episodes was in see neurology ed consult note by the then restarted about weeks ago shortly after she missed a neurology appointment because she was at a court hearing having her son evicted from her house and placed in an inpatient psych facility she reports having about events in the last weeks with today she describes the events as follows the onset always starts with a sense of dizziness which she describes as a floating detached feeling like im in the air or like i don t have a body she denies a out of body experience or vertigo she then will feel shaky especially in her legs followed by a feeling of fear anxiety she feels like i don t have any legs describing them as numb and weak her speech will then sound funny the event concludes in a non pulsatile headache with nausea and occasional emesis each event lasts about min she also describes a very similar episode which she calls her stroke at in the months following her ca treatment she denies any significant headache history on neuro ros the pt denies loss of vision blurred vision diplopia oscilopsia dysphagia vertigo tinnitus or hearing difficulty denies difficulties producing or comprehending speech denies focal weakness numbness paresthesias outside of the events no bowel or bladder incontinence or retention denies difficulty with gait on general ros the pt denies recent fever or chills no night sweats or recent weight loss or gain denies cough shortness of breath denies chest pain or tightness palpitations denies nausea vomiting diarrhea constipation or abdominal pain no recent change in bowel or bladder habits no dysuria denies arthralgias or myalgias denies rash past medical history cva mi anemia appendectomy back pain right sciatica cataracts hypertension hypothyroidism s p thyroidectomy years ago now on levothyroxine right ankle surg pins throat cancer followed at throat cancer surgery thyroidectomy tobacco abuse tonsilectomy stenosis r carotid artery device placed and removed brain tumor adenoid cystic carcinoma depression dyspnea on exertion recheck chest ct seasonal affective d o admitted to for dizziness thought to be secondary to benign paroxysmal positional vertigo also thought that symptoms exacerbated by stress due to verbal abuse experienced at home from her son social history family history strong family history of malignancy one brother deceased in his with liver malignancy another in his with lung cancer mother deceased reportedly at in the setting of multiple medical problems plus a stroke her father died at patient denies other neurologic family history other than the above physical exam admission medical examination t hr bp rr sat on ra general medical examination general appearance alert in no apparent distress conversing interacting appropriately heent sclera are non injected mucous membranes are moist cv heart rate is regular lungs breathing comfortably on ra abdomen soft non tender extremities no evidence of deformities no contractures no edema skin no visible rashes warm and well perfused neurological examination mental status alert and oriented to person place and time able to relate history without difficulty attentive to conversation language is fluent and appropriate with intact comprehension repetition and naming of both high and low frequency objects normal prosody there were no paraphasic errors speech was not dysarthric able to follow both midline and appendicular commands no neglect left right confusion or finger agnosia during a witnessed event the patient s speech became slow and effortful but not dysarthric she was still able to repeat and follow complex commands she did not demonstrate any weakness during the event cranial nerves i not tested ii visual fields full to confrontation iii iv vi pupils equally round reactive to light normal conjugated extra ocular eye movements in all directions of gaze no nystagmus or diplopia v symmetric perception of lt in v1 vii face is symmetric at rest and with activation symmetric speed and excursion with smile viii hearing intact to finger rub bl ix x palate elevates symmetrically xi shoulder shrug bl xii no tongue deviation or fasciculations motor normal muscle bulk and tone throughout no pronator drift or rebound strength delt bic tri wre ffl fe io ip quad ham ta l r reflexes brisk and symmetric toes are equivocal bilaterally sensory decreased perception to pin on the left documented in prior exams normal and symmetric perception of light touch vibration and temperature proprioception is intact coordination finger to nose without dysmetria bilaterally no intention tremor ram were slow but with regular cadence and good accuracy gait good initiation narrow based normal stride and arm swing discharge physical examination general awake alert woman in bed reporting mild headache in no acute distress heent no conjunctival injection or discharge mmm resp breathing comfortably in room air cv no cyanosis abd non distended ext wwp neuro mental status awake alert oriented to place conversant able to answer basic history questions cn perrl eomi face grossly symmetric with grossly normal facial sensation motor at least anti gravity throughout with no orbiting gait deferred pertinent results eeg preliminary report see full final report for further details multiple push button events without evidence of electrographic correlate no evidence of seizure no sharp waves intermittent right temporal slowing as expected given known lesion 50am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 50am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 50am blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 00pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 50am blood plt 50am blood ptt 00pm blood plt 00pm blood ptt 50am blood glucose urean creat na k cl hco3 angap 00pm blood glucose urean creat na k cl hco3 angap 50am blood alt ast ld ldh alkphos totbili 50am blood calcium phos mg 50am blood tsh 06pm blood lactate brief hospital course patient was admitted to the neurology service where she was placed on long term eeg to capture events multiple episodes were captured and were typical of the events of interest there were multiple push button events for these episodes without eeg correlate no evidence of seizure as a result these episodes were felt to be most likely due to stress e g possible panic attacks no medication changes were made and no new medications were added she was discharged home with a plan to follow up with her primary care physician and psychiatry medications on admission the preadmission medication list may be inaccurate and requires futher investigation aspirin mg po daily atenolol mg po daily chlorthalidone mg po daily levothyroxine sodium mcg po daily lisinopril mg po daily fish oil omega mg po daily discharge medications aspirin mg po daily atenolol mg po daily chlorthalidone mg po daily fish oil omega mg po daily levothyroxine sodium mcg po daily lisinopril mg po daily discharge disposition home discharge diagnosis anxiety discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent neuro exam non focal discharge instructions dear ms you were admitted for episodes of feeling dizzy confused floating and scared we placed you on eeg to look at your brain waves you had a few of these episodes while under eeg monitoring and they were not seizures we think that your episodes are most likely from anxiety please talk to your primary care doctor to arrange for a psychiatry appointment for management of your anxiety followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies no known allergies adverse drug reactions attending chief complaint cough sob major surgical or invasive procedure none history of present illness with pmh of htn hld who presents with cough and sob this has been developing over several weeks she denies fever chills found to have an elevated bnp to with ekg showing atrial fibrillation lad mildly prolonged qrs c w lafb 1mm ste in iii with std in i unchanged from prior twi in v1 v5 new from prior w new t wave flattening in ii v6 trops x negative also found to have hyponatremia to started on iv heparin for acs vs afib transitioned to apixiban echo pending getting iv diuresis past medical history hypertension osteoarthritis hypercholesterolemia social history family history father had prostate surgery at years and passed away at mother died at a younger age with mi a brother had myocardial infarction as well and he was a smoker no history of dementia in the family physical exam admission exam physical exam vitals t bp hr rr o2 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 gu no foley ext warm well perfused pulses no clubbing cyanosis or edema neuro cns2 intact motor function grossly normal discharge exam vitals t bp hr s rr o2 ra general alert oriented sitting up in bed and eating breakfast 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 gu no foley ext warm well perfused pulses edema in lower extremities bilaterally neuro cns2 intact motor function grossly normal pertinent results admission labs 39pm po2 pco2 ph total co2 base xs 39pm lactate 30pm alt sgpt ast sgot alk phos tot bili 30pm 30pm calcium magnesium 30pm 25pm glucose urea n creat sodium potassium chloride total co2 anion gap 25pm estgfr using this 25pm ctropnt 25pm calcium magnesium 25pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 25pm neuts monos eos basos im absneut abslymp absmono abseos absbaso 25pm plt count discharge labs 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood plt 24pm blood glucose urean creat na k cl hco3 angap 24pm blood calcium phos mg imaging impression limited exam without definite acute cardiopulmonary process specifically no visualized focal consolidation concerning for pneumonia brief hospital course ms is an with pmh of htn hld who presented to the ed with cough and doe for weeks she was found to have hyponatremia an elevated ag changes on ecg concerning for ischemia new onset atrial fibrillation and elevated bnp concerning for chf she was discharged on dyspnea cough most likely multifactorial related to new af possibly cardiac ischemia and some element of volume overload given elevated bnp of note pt endorsed a chronic dry cough for years which was per notation by cardiology likely related to lisinopril this episode was more acute however we changed to losartan to simplify future clinical presentations cxr did not show evidence of pulmonary edema or infection though exam was limited given patient s habitus w kyphosis possibly new diagnosis of chf perhaps provoked by cardiac ischemia see below vs tachycardia induced cardiomyopathy in the setting of af and h o of intermittent palpitations with pacs the latter seems less likely as patient s hr has been controlled throughout admission and she is on metoprolol at baseline lactate was slightly elevated to on admission at on acutely decompensated chf was less likely as she was warm on exam beta blockers were continued prior cardiology note described cough as possibly being acei induced she was switched from lisinopril to losartan given concern for acei induced cough she was given iv lasix mg boluses and had good urine output she will need a tte as an outpatient and cardiology follow up patient stated if she were to have evidence of ischemia on her echo she would not want a stent however with son in the room he stated she did not fully understand the implications they had many questions which will need to be concretly and clearly stated at follow up visits started on 10mg furosemide pt with follow up for weight lytes atrial fibrillation patient with af on ecg at presentation and was never noted on prior ecgs patient does have history of skipped beats for which she was evaluated by cardiology and treated with metoprolol it is possible that this may have represented af not captured on ecg her current presentation may be af provoked in the setting of chf vs cardiac ischemia or vice versa patient with chadsvasc given age htn and female sex heparin was initiated on admission for anticoagulation she was switched to apixaban mg bid and continued on home metoprolol twi on ecg patient had twi on ecg at admission may be rate related changes in the setting of new af vs related to cardiac ischemia she was without symptoms of chest pain but did have doe trops x were negative mb in discussion regarding further work up patient indicated that she would not like to have any invasive procedure should she be found to have cad she was continued on statin will follow up with her cardiologist as an outpatient hyponatremia her hyponatremia on admission was likely hypervolemic in the setting of elevated bnp and possible volume overload she had a prior history of hyponatremia which was attributed to poor po intake and improved with ivf na was on admission and improved to on with diuretics transaminitis elevated ast and alt on admission possibly due to congestion in the setting of possible chf transaminitis resolved on elevated ag patient with ag on admission that resolved on had normal ph on vbg lactate was slightly elevated delta delta suggestive of pure ag process evaluated with serum to r o salicylate toxicity in the ed which was negative patient with no history of other exposure of ingestion other possible etiology is ketonemia in the setting of decreased po intake this resolved on admission hypertension h o htn swtiched from lisinopril mg to losartan mg given concern for ace induced cough hld continued on statin transitional issues will need outpatient echo for diagnosis of chf discussed with patient and son the need for assistance with services however declined at this time over what he described were privacy issues of the patient and would need to discuss slowly over time we would like to be offered this option at a later time provided with a script for outpatient will need outpatient cardiology evaluation and possible stress test code status full name of health care proxy relationship sons phone number cell phone medications on admission the preadmission medication list is accurate and complete aspirin mg po daily lisinopril mg po daily simvastatin mg po hs vitamin d unit po daily ammonium lactate topical daily prn ketoconazole appl tp bid metoprolol succinate xl mg po daily senna mg po bid prn constipation discharge medications apixaban mg po bid rx apixaban eliquis mg tablet s by mouth twice a day disp tablet refills fluticasone propionate nasal spry ns daily rx fluticasone mcg actuation spray nasal daily each nare disp spray refills furosemide mg po daily rx furosemide mg 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 ammonium lactate topical daily prn aspirin mg po daily ketoconazole appl tp bid metoprolol succinate xl mg po daily senna mg po bid prn constipation simvastatin mg po hs vitamin d unit po daily outpatient physical therapy with pmh of htn hld who presents with cough and sob new dx of afib discharge disposition home discharge diagnosis atrial fibrillation hypervolemia 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 trouble breathing and a cough we found you to have extra fluid in your body so we gave you an intravenous form of the water pill to help you pee it out we thought your cough might be related to one of your medications called lisinopril so we switched it to another blood pressure medication losartan you were also found to have an abnormal heart rhythm called atrial fibrillation we started you on a medication called eliquis apixaban to thin out your blood and decreases your risk of having a stroke 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 f service orthopaedics allergies no known allergies adverse drug reactions attending chief complaint left lower extremity foot drop and numbness major surgical or invasive procedure l4 s1 laminectomy and fusion on with dr of present illness is a pleasant lady who is seen today with complaints of acute onset left sided footdrop and numbness since last month she has been diagnosed of severe right hip arthritis with severe restriction of the hip range of motion she has significant difficulty in mobilization because of the hip and her mobility has significantly decreased since last month because of the foot issue and she feels that she is unstable because of the left foot her examination shows are strength in her tibialis anterior and gastrosoleus in the left side she had l5 and s1 dermatomal numbness her radiographs show grade l5 s1 lytic spondylolisthesis without any instability her mri shows severe l5 s1 bilateral foraminal stenosis with bilateral lateral recess stenosis past medical history past medical history is positive for heart disease in the form of cardiomyopathy high blood pressure diabetes past surgical history is positive for cholecystectomy appendectomy left leg vein removal skin graft from left foot cataracts and left hip replacement social history family history family history is positive for cancer diabetes and heart disease physical exam last 24h nae s overnight cleared by for discharge to rehab hvac scant drainage pe vs po ra nad a ox4 nl resp effort rrr incision c d i well approximated no erythema or drainage dry dressing applied hvac drain removed sensory l2 l3 l4 l5 s1 s2 groin knee med calf grt toe sm toe post thigh r silt silt silt silt silt silt l silt silt silt silt silt silt motor flex l1 add l2 quad l3 ta l4 r l clonus no beats labs wbc a b hgb a b hct a b plt count a b na new reference range as of k new reference range as of cl co2 glucose if fasting normal provisional diabetes bun creat imaging l spine xr impression post lumbar fusion of l4 through s1 as described above with no evidence of acute hardware related complications pertinent results 35am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 18pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 10am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 35am blood plt 18pm blood plt 10am blood plt 35am blood glucose urean creat na k cl hco3 angap 10am blood glucose urean creat na k cl hco3 angap 35am blood calcium phos mg 10am blood calcium phos mg brief hospital course patient was admitted to the spine surgery service and taken to the operating room for the above procedure refer to the dictated operative note for further details the surgery was without complication and the patient was transferred to the pacu in a stable 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 on pod physical therapy and occupational therapy were consulted for mobilization oob to ambulate and adl s hospital course was otherwise unremarkable on the day of discharge the patient was afebrile with stable vital signs comfortable on oral pain control and tolerating a regular diet medications on admission the preadmission medication list is accurate and complete allopurinol mg po daily metoprolol tartrate mg po daily atorvastatin mg po qpm naproxen mg po q8h prn pain moderate cyanocobalamin mcg po daily vitamin d unit po daily discharge medications acetaminophen mg po q8h bisacodyl mg po pr daily docusate sodium mg po bid 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 every four hours disp tablet refills allopurinol mg po daily atorvastatin mg po qpm cyanocobalamin mcg po daily metoprolol tartrate mg po daily vitamin d unit po daily discharge disposition extended care facility discharge diagnosis lumbar spinal stenosis l5 s1 l5 s1 grade i ii isthmic lytic spondylolisthesis right lower extremity radiculopathy with foot drop lumbar degenerative disc disease likely osteoporosis 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 lumbar decompression with fusion you have undergone the following operation lumbar decompression with fusion immediately after the operation activity you should not lift anything greater than lbs for weeks you will be more comfortable if you do not sit or stand more than minutes without getting up and walking around rehabilitation physical times a day you should go for a walk for minutes as part of your recovery you can walk as much as you can tolerate limit any kind of lifting diet eat a normal healthy diet you may have some constipation after surgery you have been given medication to help with this issue brace you may have been given a brace if you have been given a brace this brace is to be worn when you are walking you may take it off when sitting in a chair or while lying in bed wound care weight bearing as tolerated gait balance training no lifting lbs no significant bending twisting you should resume taking your normal home medications you have also been given additional medications to control your pain please allow hours for refill of narcotic prescriptions so please plan ahead you can either have them mailed to your home or pick them up at the clinic located on we are not allowed to call in or fax narcotic prescriptions oxycontin oxycodone percocet to your pharmacy in addition we are only allowed to write for pain medications for days from the date of surgery follow up please call the office and make an appointment for weeks after the day of your operation if this has not been done already at the week visit we will check your incision take baseline x rays and answer any questions we may at that time start physical therapy we will then see you at weeks from the day of the operation and at that time release you to full activity please call the office if you have a fever degrees fahrenheit and or drainage from your wound physical therapy weight bearing as tolerated gait balance training no lifting lbs no significant bending twisting treatments frequency dry dressing daily until your follow up appointment do not soak the incision in a bath or pool if the incision starts draining at anytime after surgery do not get the incision wet call the office at that time followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies no known allergies adverse drug reactions attending chief complaint fall with headstrike major surgical or invasive procedure none history of present illness neurosurgery admission is a female who presents to on with a mild tbi patient has a pmh of afib on coumadin ckd alzheimers dementia and presents s p a witnessed fall this afternoon at her nursing facility patient was brought to osh for evaluation upon arrival to osh patient had a nchct done that showed an acute on chronic sdh with 8cm of midline shift patient was found to have an inr of and she received kcentra and vitamin k for reversal patient was transferred to for further evaluation and neurosurgery was consulted upon examination in ed patient was alert and oriented to self baseline year and hospital with choices she was strength throughout and did not have pronator drift patient has dementia at baseline unable to provide pmh so history obtained through ed report mechanism of trauma fall past medical history afib on coumadin alzheimer s dementia ckd nephrectomy with unilateral kidney social history family history unknown physical exam on admission physical exam t hr bp rr spo2 ra gcs at the scene gcs upon neurosurgery evaluation time of evaluation airway intubated x not intubated eye opening does not open eyes opens eyes to painful stimuli opens eyes to voice x opens eyes spontaneously verbal makes no sounds incomprehensible sounds inappropriate words x confused disoriented oriented motor no movement extension to painful stimuli decerebrate response abnormal flexion to painful stimuli decorticate response flexion withdrawal to painful stimuli localizes to painful stimuli x obeys commands exam gen wd wn comfortable nad neuro mental status awake alert cooperative with exam normal affect orientation oriented to person place hospital with choices and date with choices language speech is fluent with good comprehension if intubated cough gag over breathing the vent cranial nerves i not tested ii pupils equally round and reactive to light 3mm to 2mm bilaterally visual fields are full to confrontation iii iv vi extraocular movements intact bilaterally without nystagmus v vii facial strength and sensation intact and symmetric viii hearing intact to voice ix x palatal elevation symmetrical xi sternocleidomastoid and trapezius normal bilaterally xii tongue midline without fasciculations motor normal bulk and tone bilaterally no abnormal movements tremors strength full power throughout no pronator drift sensation intact to light touch handedness right discharge physical exam vs hr data last updated temp tm bp hr rr o2 sat o2 delivery ra t bp hr rr o2 ra heent at nc anicteric sclera and without injection mmm cv rrr s1 s2 no murmurs gallops or rubs pulm ctab no wheezes rales rhonchi breathing comfortably on ra gi abdomen soft bs nondistended nontender no suprapubic tenderness extremities no cyanosis clubbing or edema skin warm and well perfused no visible rash neuro a ox1 to self moving all extremities with purpose face symmetric pertinent results admission labs 01pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 01pm blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 01pm blood ptt 01pm blood glucose urean creat na k cl hco3 angap 01pm blood calcium phos mg 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 ctropnt 33am blood ctropnt 45am blood calcium phos mg other pertinent labs micro 11pm urine color straw appear clear sp 11pm urine blood neg nitrite neg protein neg glucose neg ketone neg bilirub neg urobiln normal ph leuks sm 11pm urine rbc wbc bacteri none yeast none epi 11pm urine mucous rare pm urine final report urine culture final mixed bacterial flora colony types consistent with skin and or genital contamination 00pm blood lactate 31pm urine color straw appear hazy sp 31pm urine blood neg nitrite neg protein glucose neg ketone neg bilirub neg urobiln ph leuks mod 31pm urine rbc wbc bacteri few yeast none epi renalep 31pm urine mucous few pertinent imaging ct head wo contrast impression acute on chronic left subdural hematoma interval slightly increased in size compared to the previous study with slightly worsening mm midline shift to the right and subfalcial herniation small right sided subdural collection again seen which contains a small dense component anterior to the frontal lobe also suggesting acute on chronic subdural hematoma no significant mass effect related to the right subdural collection ekg atrial fibrillation with rapid ventricular response hr lock abnormal ecg when compared with ecg of a fib has replaced sinus rhythm qtc ekg qtc with qrs duration 140ms ekg qtc ekg qtc ct head wo contrast impression redemonstration of mixed density subdural hematoma overlying the left frontoparietal convexity measuring cm in maximum thickness not significantly changed in comparison to the prior study there is associated mass effect with unchanged sulcal effacement and mm of rightward midline shift and subfalcine herniation small right sided subdural hematoma overlying the right frontal convexity not significantly changed in comparison to the prior study no evidence of acute large territory infarction or new hemorrhage brief hospital course summary is a year old female who presented to osh s p an unwitnessed fall at her nursing home cth at osh significant for a left sdh and the patient was transferred for neurosurgical evaluation discussion was held with the patient s family and an mma embolization was offered and the family declined intervention patient was then transferred to medicine where she remained stable and was recommended to go to rehab by physical therapy transitional issues pt will continue to hold any anticoagulation until follow up with dr in week with a repeat head ct follow up chemistry on to monitor electrolytes and kidney function held several medications due to prolonged qtc recommend rechecking ekg as outpatient and consider restarting appropriate meds sertraline held due to prolonged qtc consider alternative antidepressant amiodarone held this admission due to prolonged qtc although was still having rvr earlier in admission on amio consider adjusting regimen for atrial fibrillation ensure enlive 4x day encourage po intake manage constipation acute issues acute on chronic sdh unwitnessed fall at her nursing home cth at osh significant for a left sdh and the patient was transferred for neurosurgical evaluation patient was taking coumadin for history of afib and inr at osh was kcentra and vitamin k was given and inr on arrival to our ed was patient was admitted to the neurosurgery service and transferred to the from the ed coumadin was held on admission patient remained what appeared to be at her neurological baseline cth in the am on revealed a slightly larger left sdh and a very small right frontal sdh discussion was held with the patient s family and an mma embolization was offered and the family declined intervention on the patient s neurologic checks were liberalized and she was transferred to the floor given vomiting had repeat ct head which was stable from prior atrial fibrillation on coumadin chads vasc for age and female gender on warfarin amiodarone and metoprolol at home this admission patient was continued on metoprolol and had episodes of rvr as well as episodes of bradycardia metoprolol was adjusted to prior home dose and hrs remained stable amiodarone was held in the setting of prolonged qtc warfarin was held in setting of acute on chronic sdh with plans to continue holding until week follow up nchct with neurosurgery prolonged qtc noted on initial ecgs likely secondary to multiple medications that can prolong the qtc several medications were stopped and repeat ekg with qtc later in hospital course qtc was rechecked and was in 500s continued to hold home medications that can contribute to prolonged qtc at time of discharge pt with cr during admission in setting of poor po intake improved with ivf also with orthostasis with sbp 100s lying down to standing as well as decreased uop s p another 1l lr and no longer orthostatic with improved urine output cr on discharge was asymptomatic pyuria ua with wbc and moderate leuks however patient was asymptomatic and without dysuria or suprapubic tenderness on exam had leukocytosis to later in admission which resolved after ivf possibly representing hemoconcentration overall not concerning for active infection fall unwitnessed fall at nursing home unclear what work up was performed at osh here she has had episodes of rvr on telemetry no murmurs on exam to suggest valvular pathology no infectious signs symptoms orthostasis is possible however bps have been stable this admission likely etiology was mechanical fall as etiology evaluated by and recommended to go to rehab heartburn gerd on day of discharge patient reported epigastric and left sided chest pain as well as nausea and lightheadedness received tums and symptoms completely resolved also received aspirin x1 however low suspicion for cardiac etiology ekg obtained and was stable from prior no st or t wave changes vitals were stable during the event trops x2 likely represented heartburn reflux given rapid improvement with tums was given maalox diphenhydramine lidocaine for symptoms had also been receiving home ppi daily during admission vomiting constipation pt with vomiting x2 later in admission not taking much po as a result ct head stable from prior pt asymptomatic and denied abd pain n v at those times no localizing symptoms suspect constipation a large driver increased bowel regimen pt did not have further episodes of vomiting and remained asymptomatic t2 and t4 compression fractures diagnosed at osh per family she suffered a fall about weeks ago and was dx with a t2 and t4 compression fracture at that time she was discharged from the ed without intervention and recommendation to follow up with her pcp who ordered tlso brace she has no back pain or midline spinal tenderness and has been ambulating without any brace for week now neurosurgery felt that she did not require a brace or any further intervention it was felt that she may continue activity as tolerated anion gap metabolic acidosis progressively downtrended bicarb in the absence of clear etiology no uremia lactate wnl ua without evidence of ketones no significant diarrhea improving at the time of discharge nutrition concerns about poor po intake from nursing staff and son by nutrition who recommended ensure enlives per day pt was given thiamine 100mg daily as well as phosphorus repletion chronic issues ckd cr remained wnl and stable this admission hld continued on home simvastatin 10mg qpm hypothyroidism continued on home levothyroxine 50mcg daily alzheimers continued on home memantine 5mg po bid ramelteon 8mg qpm prn depression held home sertraline in setting of prolonged qtc medications on admission the preadmission medication list is accurate and complete acetaminophen mg po bid prn pain mild fever amiodarone mg po every other day ferrous sulfate mg po bid levothyroxine sodium mcg po daily memantine mg po bid metoprolol tartrate mg po bid pantoprazole mg po every other day sertraline mg po daily simvastatin mg po qpm warfarin mg po daily tramadol mg po q6h prn pain moderate gabapentin mg po qam gabapentin mg po qhs melatonin mg oral qhs discharge medications calcium carbonate mg po qid prn heartburn polyethylene glycol g po daily pantoprazole mg po q24h acetaminophen mg po bid prn pain mild fever ferrous sulfate mg po bid gabapentin mg po qam gabapentin mg po qhs levothyroxine sodium mcg po daily melatonin mg oral qhs memantine mg po bid metoprolol tartrate mg po bid simvastatin mg po qpm held amiodarone mg po every other day this medication was held do not restart amiodarone until you see your primary care doctor held sertraline mg po daily this medication was held do not restart sertraline until you see your primary care doctor held tramadol mg po q6h prn pain moderate this medication was held do not restart tramadol until you see your doctor held warfarin mg po daily this medication was held do not restart warfarin until you see dr in a few weeks discharge disposition extended care facility discharge diagnosis primary diagnosis left acute on chronic sdh small right acute sdh secondary diagnosis prolonged qtc atrial fibrillation anion gap metabolic acidosis discharge condition mental status confused always level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear ms you came into the hospital after a fall and were found to have new bleeding in your brain as well as findings of old bleeding you were monitored closely and you did not require surgical intervention some of your home medications were also adjusted please see the medication changes listed below for the complete list it was a pleasure taking care of you your medicine team activity we recommend that you avoid heavy lifting running climbing or other strenuous exercise until your follow up appointment you make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest try to do too much all at once no driving while taking any narcotic or sedating medication if you experienced a seizure while admitted you are not allowed to drive by law no contact sports until cleared by your neurosurgeon you should avoid contact sports for months medications please do not take any blood thinning medication aspirin ibuprofen plavix coumadin until cleared by the neurosurgeon you may use acetaminophen tylenol for minor discomfort if you are not otherwise restricted from taking this medication what you experience you may have difficulty paying attention concentrating and remembering new information emotional and or behavioral difficulties are common feeling more tired restlessness irritability and mood swings are also common constipation is common be sure to drink plenty of fluids and eat a high fiber diet if you are taking narcotics prescription pain medications try an over the counter stool softener headaches headache is one of the most common symptom after a brain bleed most headaches are not dangerous but you should call your doctor if the headache gets worse develop arm or leg weakness increased sleepiness and or have nausea or vomiting with a headache mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor there are other things that can be done to help with your headaches avoid caffeine get enough sleep daily exercise relaxation meditation massage acupuncture heat or ice packs when to call your doctor at for severe pain swelling redness or drainage from the incision site fever greater than degrees fahrenheit nausea and or vomiting extreme sleepiness and not being able to stay awake severe headaches not relieved by pain relievers seizures any new problems with your vision or ability to speak weakness or changes in sensation in your face arms or leg call and go to the nearest emergency room if you experience any of the following sudden numbness or weakness in the face arm or leg sudden confusion or trouble speaking or understanding sudden trouble walking dizziness or loss of balance or coordination sudden severe headaches with no known reason 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 s p mvc major surgical or invasive procedure left iliac vein and ivc venogram infrarenal retrievable denali ivc filter deployment post filter placement venogram open reduction internal fixation right femur open reduction internal fixation left ankle open reduction internal fixation left distal tib fib joint tracheostomy percutaneous endoscopic gastrostomy tube placement peg revision ankle fixation with fixation of distal tibia anterolateral corner and refixation of fibula and syndesmosis interventional radiology conversion of peg to gj tube history of present illness year old female who presents to ed on after a motor vehicle collision upon arrival a shows right subdural hematoma right traumatic subarachnoid hemorrhage as well as a c1 fracture with possible ica injury past medical history pmh dm hypothyroidism unclear liver disease per family psh unknown social history family history non contributory physical exam admission physical exam general intubated heent normocephalic atraumatic resp intubated cv regular rate and rhythm abd nondistended msk shortening and external rotation of right lower extremity with deformity over the thigh lateral dislocation of the left ankle pulses intact patient spontaneously moves toes ecchymosis without bony deformity or crepitus to right elbow skin no rash warm and dry no petechiae neuro spontaneously moves all extremities responds to pain with nonpurposeful movement discharge physical exam gen chronically ill appearing but non verbally interactive with staff heent ncat eomi no scleral icterus cv irregularly irregular rhythm radial pulses b l resp breathing comfortably on tracheostomy with humidified air gi soft non ttp no r g d no masses left sided gj tune ext warm and well perfused lle in orthopedic booth left dl picc line right hand in protective mitt pertinent results imaging ecg baseline artifact sinus rhythm non specific repolarization abnormalities q t interval is not well seen as t wave is indistinct but is likely prolonged no previous tracing available for comparison ct c spine large hematoma centered in the right carotid space is highly concerning for acute injury to the right carotid artery and urgent cta of the head and neck is recommended avulsion of the alar ligaments at the level of the dens raises concern for craniocervical instability acute fractures involving the anterior posterior ring of c1 difficult to exclude injury to the transverse ligament given asymmetry at c1 small extra axial hematoma at the level of c1 recommend correlation with mri skullbase and facial fractures are better described on the maxillofacial ct from the same date ct head mm right cerebral subdural hematoma no significant midline shift tiny right cerebral subarachnoid hemorrhage and right frontal vertex contusion depressed comminuted fracture of the right squamous temporal bone no associated epidural hematoma please refer to same day ct facial bone and ct c spine for details regarding facial and cervical spine injuries cxr low lying et tube requires approximately cm retraction for more optimal positioning esophageal ph probe and orogastric tubes appear well positioned right femur x ray displaced and angulated right midshaft femur fracture comminuted ct chest abdomen pelvis hematoma tracks along the right common carotid artery into the superior mediastinum please refer to the cta head and neck performed on the same date for a complete description of injury to the right carotid artery endotracheal tube terminates cm above the carina as seen on chest x ray slight retraction of the endotracheal tube is recommended right quadriceps hematoma is partially seen on this study which is most likely related to the comminuted femoral shaft fracture better characterized on pelvic and femur radiographs from the same date close clinical observation for compartment syndrome is recommended minimally displaced posterior right eleventh and twelfth rib fractures ct sinus mandible maxillofacial w o contrast multiple facial bone fractures right greater than left with proptotic right globe and right extraconal hematoma mild prominence of the right lateral rectus muscle raises potential concern for contusion straightening of the right optic nerve should be correlated with vision exam bilateral maxillary sinus fractures right squamous temporal bone fracture better assessed on same day head ct cta head neck complete transection of the right internal carotid artery about cm above the bifurcation with extravasation into the adjacent carotid sheath hematoma causing mass effect on the right jugular vein the left ica appears normal without evidence of stenosis occlusion or dissection the vertebral arteries appear normal bilaterally irregularity and narrowed caliber of the cavernous segment of the intracranial portions of the right internal carotid artery are concerning for dissection distal reconstitution of the intracranial portions of the right ica is likely from collaterals in the left anterior and posterior circulation as such the vessels of the circle of are patent without stenosis occlusion or aneurysm formation known acute fractures of the left posterior maxillary sinus anterior and posterior arch of c1 lateral wall of the right orbit as well as small right frontal subdural hematoma are better seen on the same day dedicated ct head and maxillofacial exam patient is intubated an oral catheter is also incidentally noted elbow ap lat oblique right port no acute fx left ankle x ray acute fractures involving the distal fibular shaft and medial malleolus tib fib ap lat left acute fractures involving the distal shaft fibula and medial malleolus mri mra brain and mra stable small right subdural hematoma blood within the occipital horns of the lateral ventricles is more conspicuous than on the prior ct which may be due to differences in modalities stable small right superior frontal hemorrhagic contusion versus hemorrhagic diffuse axonal injury several punctate foci of slow diffusion at the gray white junction in the right frontal lobe may represent tiny embolic infarcts or nonhemorrhagic diffuse axonal injury small focus of hypointense signal in the left dorsal midbrain on gradient echo images which may represent a chronic microhemorrhage as there is no associated acute diffusion abnormality diffuse bilateral sulcal flair hyperintensity without associated abnormality on gradient echo images may be secondary to intubated status and supplemental oxygen therapy rather than interval increase in previously minimal subarachnoid hemorrhage this could be clarified on follow up ct x mm medially projecting pseudoaneurysm of the distal right cervical internal carotid artery at c2 the internal carotid artery in the internal jugular vein are moderately compressed by the pseudoaneurysm distal to the pseudoaneurysm there is reconstitution of flow in the right internal carotid artery with normal caliber distal to the level of c2 representing improvement compared to turbulent flow in the proximal basilar artery blood within the paranasal sinuses secondary to multiple facial fractures which are better demonstrated on the chest port line placem compared to a chest radiographs earlier on tip of the endotracheal tube with the chin elevated is less than cm from the carina it should be withdrawn cm to avoid unilateral intubation particularly with chin flexion left subclavian line ends close to the superior cavoatrial junction transesophageal drainage tube loops in the stomach and passes at least as far as the pylorus and out of view previous left lower lobe peribronchial opacification has improved lungs are essentially clear heart size normal no pleural effusion or pneumothorax knee views right fracture of the lateral tibial plateau of the knee single pin traversing the proximal tibial metadiaphysis ankle views right overall improved congruency of the ankle mortise resolved posterior displacement but new lateral displacement of the distal fibular fracture improved alignment of the medial malleolar fracture lateral distal tibial metaphyseal fracture faintly visualized without significant displacement ct head w o contrast increase in extent of subarachnoid hemorrhage now involving bilateral hemispheres persistent right convexity subdural hematoma carotid cerebral stenti successful restoration of flow into the right cervical internal carotid artery status post dissection with contrast stagnation in the pseudoaneurysm femur ap lat right in comparison with the study of there has been substantial improvement in the alignment of the comminuted fracture of the midshaft of the femur following the application of traction otherwise little change cxr compared to chest radiographs endotracheal tube left subclavian line and esophageal drainage tube are in standard placements lungs clear heart size normal no pleural abnormality cta pelvis w w o c re soft tissue stranding surrounding the bilateral common femoral arteries related to bilateral femoral angiograms performed earlier on same day with no evidence of active arterial or venous extravasation small amount of nonocclusive thrombus in the right external iliac vein at the site of a recent femoral central venous catheter re demonstration of a comminuted and displaced right femoral shaft fracture with no evidence of associated vascular injury re demonstration of a right quadriceps hematoma with no evidence of active extravasation a partially visualized right tibial plateau fracture is better evaluated on ct right lower extremity performed on same day ct low ext w o c right sagittally oriented nondisplaced lateral tibial plateau fracture with intra articular extension large knee joint lipohemarthrosis with extensive soft tissue swelling subchondral cystic changes of the medial tibiofemoral compartment consistent with degenerative joint disease external fixation device is noted through the proximal tibia without evidence of hardware complication ct head stable appearance extensive subarachnoid hemorrhage involving the bilateral cerebral hemispheres and small right frontoparietal subdural hematoma compared to prior same day ct exam no new focus of hemorrhage or acute major vascular territory infarction is identified multiple known fractures are better assessed on the dedicated ct maxillofacial exam from ivc gram filter successful deployment of retrievable denali ivc filter eeg this is an abnormal continuous icu monitoring study because of diffusely slow background indicative of a moderate to severe encephalopathy which is non specific as to etiology there are no focal abnormalities electrographic seizures or epileptiform discharges lower extremity fluoro postoperative changes with tibia fibula arthrodesis medial malleolar screw and plate screw fixation of the distal fibula soft tissue swelling ankle views in o r postoperative changes with tibia fibula arthrodesis medial malleolar screw and plate screw fixation of the distal fibula soft tissue swelling lower extremity fluoro intramedullary rod in place right femur femur ap lat in o r intramedullary rod in place right femur eeg this is an abnormal continuous icu monitoring study because of diffuse slowing of the background indicative of a moderate encephalopathy which is non specific as to etiology there are no focal abnormalities electrographic seizures or epileptiform discharges compared to the prior day s recording there are no significant changes ct head overall stable study from most recent examination on unchanged right proptosis ct low ext w o c left postoperative changes consistent with orif of the distal tibia and fibula a vertically oriented fracture through the anteromedial tibia is not transfixed by the surgical hardware no hardware complications detected fracture lines remain visible findings suggestive of mild plantar fasciitis cxr compared to chest radiographs left subclavian line are probably has migrated into the azygos vein ett in standard placement transesophageal drainage tube passes into the mid stomach and out of view mild left lower lobe atelectasis has developed small bilateral pleural effusions are also new upper lungs clear heart size normal no pneumothorax eeg this is an abnormal continuous icu monitoring study because of diffuse slowing of the background indicative of a moderate encephalopathy which is non specific as to etiology there are no focal abnormalities electrographic seizures or epileptiform discharges compared to the prior day s recording there are no significant changes eeg this is an abnormal continuous icu monitoring study because of diffuse slowing of the background indicative of a moderate encephalopathy which is non specific as to etiology there are no focal abnormalities electrographic seizures or epileptiform discharges compared to the prior day s recording there are no significant changes cxr interval improvement in retrocardiac opacity with some residual patchy opacity and probable small left and right pleural effusions no overt chf elbow ap lat views r there is no fracture bilat lower ext veins completely occlusive thrombus involving all of the posterior tibial and peroneal veins bilaterally ct sinus mandible maxil dental amalgam streak artifact limits study grossly stable appearance of multiple facial right temporal bone calvarial and c1 fractures gas containing fluid collections in the right maxillary sinus and bilateral sphenoid sinuses are non specific and may represent blood products acute sinusitis and or may be related to intubation status previously seen right carotid hematoma surrounding right ica stent now measures up to cm periodontal disease of multiple maxillary teeth as described bilat up ext veins us no evidence of deep vein thrombosis in the bilateral upper extremity veins bilateral internal jugular veins could not be evaluated due to c collar bilateral cephalic veins were not visualized lower extremity fluoro several intraoperative images demonstrate placement of hardware within the distal fibula and tibia this includes syndesmotic screws there is widening of the superior portion of the tibiotalar joint no hardware related complications are identified total intraservice fluoroscopic time was seconds please refer to the operative note for additional details ankle ap mortise la several intraoperative images demonstrate placement of hardware within the distal fibula and tibia this includes syndesmotic screws there is widening of the superior portion of the tibiotalar joint no hardware related complications are identified total intraservice fluoroscopic time was seconds please refer to the operative note for additional details ct head w w o contra compared with the head ct from no new acute intracranial hemorrhage or large vascular territorial infarction evolving bilateral subarachnoid hemorrhages and right subdural hematoma which have become less conspicuous by imaging small amount of residual intraventricular hemorrhage in the occipital horn of the left lateral ventricle multiple known facial right temporal bone and calvarial fractures were better characterized on the ct facial bone study from chest portable ap comparison to no relevant change the tracheostomy tube and the left picc line are stable borderline size of the heart no pneumonia no pulmonary edema no pleural effusions no pneumothorax femur ap lat right interval internal fixation with some callus formation across mid femoral fracture 41am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 28am blood 41am blood 50am blood 41am blood glucose urean creat na k cl hco3 angap 41am blood calcium phos mg 30am blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg brief hospital course icu course ms was admitted to the after an mvc trauma workup showed multiple lower extremity fractures b l facial fractures sdh sah iph right ica transection n she went to the or with neurosurgery emergently for a right ica stent and postop was started on aspirin and ticagrelor for dual antiplatelet therapy her sah was noted to increase in size shortly after arrival to the tsicu but no intervention was performed by neurosurgery her neuro exam remained poor but stable cv she did require vasopressors during the initial part of her hospitalization but was eventually able to wean off pressors and remain hemodynamically stable pulm pt was intubated at the scene due to concern for head injury due to her poor neurologic status she eventually underwent placement of a tracheostomy and tolerated this well she was also treated with ceftriaxone for e coli vap gi due to acute critical illness she was initially kept npo once appropriate for feeding she underwent placement of a peg tube and her tube feeds were advanced to goal and tolerated well endocrine her blood glucose levels were monitored and treated appropriately with ssi heme after her right ica stent she was started on dual antiplatelet therapy she was also started on a heparin gtt for dvt which was eventually transitioned to coumadin she also had a prophylactic ivc filter placed msk she had multiple fractures of her lower extremities and underwent orif of her right femur and left ankle with orthopedic surgery the left ankle orif required revision but she tolerated all these procedures well with no complications she had c1 fractures for which she was kept in a c collar id she was persistently febrile fever workup revealed e coli which was treated with ceftriaxone dvt as possible causes however the fevers persisted and it was thought that there was possibly a central component to them her wbc eventually normalized floor course n the patient remained alert since being transferred to the floor the patient was able to give a thumbs up on her right hand when asked and was moving her right sided extremities but remained unable to move on her left side the son was spoken with bedside and reports she has attempted to talk with him on a daily basis respiratory therapy downsized and adjusted her tracheostomy tube on and the patient was able to minimally verbally communicate with staff and family cv the patient remained stable from a cardiac standpoint ekgs were checked daily to monitor qtc when starting reglan and antibiotics that prolong the qt interval pulm on the patient had emesis soon after receiving her am medications and there was concern for aspiration the patient desaturated to the high and was suctioned and saturation returned to high on tm chest x ray was ordered and sputum cultures were obtained which demonstrated e coli and she was again started on iv ceftriaxone for vap repeat imaging of the next several days demonstrated a large rll pneumonia for which she was started on vancomycin zosyn and fluconazole her vancomycin levels were difficult to control and required frequent vanco trough levels to titrate her doses to a therapeutic level her antibiotics were discontinued prior to her discharge and she remained afebrile in the several days leading up to her discharge gi the patient continued on tube feeds her rate was decreased from an original goal of ml hr to m l per hour in the presence of aspiration risk on her peg tube was converted to a gj tube by the team and she was restarted on tube feeds with the previous goal of endocrine her blood glucose levels were monitored and treated appropriately with ssi heme after her right ica stent she was started on dual antiplatelet therapy she was also started on a heparin gtt for dvt which was eventually transitioned to coumadin she also had a prophylactic ivc filter placed by shortly after admission msk she had multiple fractures of her lower extremities and underwent orif of her right femur and left ankle with orthopedic surgery the left ankle orif required revision but she tolerated all these procedures well with no complications she had c1 fractures for which she was kept in a c collar id she was persistently febrile fever workup revealed e coli which was treated with ceftriaxone dvt as possible causes however the fevers persisted and it was thought that there was possibly a central component to them her wbc eventually normalized she was later found to have a rll pneumonia likely secondary to a previous aspiration event she was started on the appropriate antibiotics as above and her intermittent fevers became less frequent on hd48 the patient was deemed clinically stable and appropriate for discharge to a rehabilitation facility with appropriate follow up clinic visits scheduled medications on admission unknown discharge medications acetaminophen liquid mg po q6h prn pain mild acetylcysteine ml neb q4h prn mucus plugging artificial tear ointment appl both eyes prn dry eyes aspirin mg po daily bisacodyl mg pr qhs prn constipation chlorhexidine gluconate oral rinse ml oral bid glargine units breakfast glargine units bedtime insulin sc sliding scale using reg insulin ipratropium albuterol neb neb neb q6h levothyroxine sodium mcg po daily metoclopramide mg po qidachs metoprolol tartrate mg po bid milk of magnesia ml po q6h prn constipation nystatin oral suspension ml po qid prn thrush oxycodone liquid mg po q4h prn pain moderate rx oxycodone mg ml ml per j tube every eight hours refills pantoprazole mg po q24h ticagrelor mg po bid duration months md to order daily dose po daily16 metformin glucophage mg po bid discharge disposition extended care facility discharge diagnosis polytrauma right subdural hematoma right traumatic subarachnoid hemorrhage c1 fracture complete transection of the right internal carotid artery right orbit lateral wall fracture acute fracture of the left posterior maxillary sinus temporal bone fracture right side rib fractures right femur fracture right tibial plateau fracture left ankle fracture right external iliac vein thrombosis secondary malnutrition secondary to dysphagia hospital acquired pneumonia central line associated blood stream infection urinary tract infection discharge condition mental status confused sometimes level of consciousness alert and interactive activity status out of bed with assistance to chair or wheelchair discharge instructions ms you were to after a motor vehicle collision you sustained serious injuries including bleeding in your head traumatic brain injury injury to your right carotid artery and multiple fractures to your face ribs right leg and left ankle regarding the life threatening injury to your right carotid artery you were first taken to the interventional radiology team and neuroendovascular team for stenting and ivc filter placement for the right internal carotid artery transection and right external iliac vein thrombosis to protect the stent and repair to your carotid artery you should remain on aspirin and ticagrelor brilinta for the next months or until instructed otherwise neurosurgery was consulted regarding your traumatic brain injury and your c1 vertebral fracture and recommended that you continue to wear the hard c collar for the next months until you follow up with dr in clinic as an outpatient regarding your multiple orthopedic injuries you received an open reduction and internal fixation of your femur and ankle fractures and will require substantial rehab efforts during your recovery you should not bear any weight on your right leg and may bear weight on your left leg as tolerated you also required the placement of a tracheostomy tube which assists in your breathing this tube will need to remain in for some time the tracheostomy tube should be changed to a smaller tube that will allow you to speak with some practice the rehab facility will assist in this issue and should do so within weeks of your discharge due to your inability to safely swallow liquids or solid foods while in the hospital we placed a feeding tube that advances from your skin into your stomach and proximal portions of your small intestines this will allow your medical teams to administer tube feeds to maintain your nutrition until you are deemed safe and appropriate to take nutrition by your mouth the tube will be maintained by your rehab facility and should be frequently flushed to avoid clogging instructions after orthopaedic surgery you were in the hospital for orthopedic surgery it is normal to feel tired or washed out after surgery and this feeling should improve over the first few days to week resume your regular activities as tolerated but please follow your weight bearing precautions strictly at all times activity and weight bearing non weight bearing left lower extremity weight bearing as tolerated right lower extremity medications please take all medications as prescribed by your physicians at discharge continue all home medications unless specifically instructed to stop by your surgeon do not drink alcohol drive a motor vehicle or operate machinery while taking narcotic pain relievers narcotic pain relievers can cause constipation so you should drink eight 8oz glasses of water daily and take a stool softener colace to prevent this side effect anticoagulation you will need to be on several anti platelet and anticoagulating medications to protect from blood clots and injury to your recently fixed carotid artery injury you will need to take coumadin daily for the foreseeable future with a goal inr of as above you should also take aspirin and ticagrelor brilinta for months wound care you may shower no baths or swimming for at least weeks all sutures and staples have been removed please remain in your dressing and do not change unless it is visibly soaked or falling off splint must be left on until follow up appointment unless otherwise instructed do not get splint wet 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 good luck 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 fever tachycardia major surgical or invasive procedure injury burden from prior admission s p mvc right subdural hematoma right traumatic subarachnoid hemorrhage c1 fracture complete transection of the right internal carotid artery right orbit lateral wall fracture acute fracture of the left posterior maxillary sinus temporal bone fracture right side rib fractures right femur fracture right tibial plateau fracture left ankle fracture right external iliac vein thrombosis secondary malnutrition secondary to pneumonia central line associated blood stream infection urinary tract infection recent admission no surgical interventions history of present illness year old female s p mvc resulting in multiple fractures s p orif right internal carotid injury managed non op b l facial fractures non op s p trach s p peg conversion to gj on home tfs sdh sah iph who was discharged from to rehab on after a prolonged hospital course now presenting from rehab febrile to per report and tachycardic to 140s in the ed past medical history pmh dm hypothyroidism unclear liver disease per family psh unknown social history family history non contributory physical exam physical exam upon admission vitals tcurrent hr bp rr o2 sat on tm mist general nad nontoxic appearing resting comfortably on hospital stretcher in ed heent normocephalic atraumatic eomi mmm trach in place with no signs of surrounding skin breakdown no signs of oral thrush resp nonlabored breathing on tm mist coarse cough bilaterally nonproductive diminished breath sounds on right side compared to left cv rrr palpable peripheral pulses abd soft nontender nondistended no rebound or guarding gu foley in place draining clear yellow urine neuro cn grossly intact moves all extremities spontaneously discharge physical exam tm gen a o resting comfortably in nard j collar in place cv ns1 s2 no murmurs lungs coarse bs bil abdomen soft non tender g tube site clean and dry ext dp bil no calf tenderness bil no pedal edema bil knee immoblizer left knee neuro opens eyes follows simple commands pertinent results 40am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 20am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30am blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 40am blood plt 40am blood ptt 20am blood plt 20am blood 00am blood plt 00am blood 40am blood glucose urean creat na k cl hco3 angap 20am blood glucose urean creat na k cl hco3 angap 40am blood calcium phos mg 20am blood calcium phos mg cxr worsened airspace opacification in the right lung is concerning for pneumonia possibly due to chronic aspiration because of recurrent pneumonias the presence of a tracheo esophageal fistula should be considered ct abd pelvis multifocal pneumonia involving the dependent portions of the right upper and lower lobes as well as a small portion of the left lower lobe given the distribution and existing tracheostomy tube aspiration pneumonia is a likely etiology no identifiable pathology in the abdomen or pelvis mal positioned left picc line terminating in the azygos vein cxr the tip of the left picc line now projects over the upper svc airspace opacities throughout the right lung and left base have slightly decreased cxr mild interval decrease in right base consolidation consistent with resolving pneumonia ct c spine grossly unchanged appearance of the left c1 posterior arch fracture with no significant interval osseous callus formation since stable multiple sub cute fractures of the skull base no new fractures unchanged mild multilevel degenerative changes of the cervical spine am blood culture final report blood culture routine final staphylococcus coagulase negative isolated from only one set in the previous five days sensitivities performed on request aerobic bottle gram stain final gram positive cocci in pairs and clusters reported to and read back by 09am am urine final report urine culture final yeast cfu ml am sputum source endotracheal final report gram stain final pmns and epithelial cells 100x field no microorganisms seen respiratory culture final commensal respiratory flora absent escherichia coli sparse growth cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h klebsiella pneumoniae sparse growth cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h sensitivities mic expressed in mcg ml escherichia coli klebsiella pneumoniae ampicillin s ampicillin sulbactam s s cefazolin s s cefepime s s ceftazidime s s ceftriaxone s s ciprofloxacin s s gentamicin s s meropenem s s piperacillin tazo s s tobramycin s s trimethoprim sulfa s s pm stool consistency formed source rectal swab final report c difficile dna amplification assay final negative for toxigenic c difficile by the cepheid nucleic acid amplification assay reference range negative brief hospital course yo female s p mvc presenting with multiple lower extremity fractures s p orif right internal carotid injury managed non op bilateral facial fractures non op s p trach s p peg conversion to gj on home tfs sdh sah iph who was discharged from to rehab on after a prolonged hospital course she re presented to the hospital from rehab on with a fever to and tachycardia to she reportedly had a white blood cell count of upon admission the patient was made npo given intravenous fluids and underwent imaging a cat scan of the torso showed multi focal pneumonia the patient was started on intravenous vancomycin and zosyn blood sputum and urine cultures were obtained on review of imaging the picc line was reported to be mal positioned it was repositioned and chest ray imaging showed it projecting over the upper svc during the patient s hospitalization imaging studies of the head and neck were repeated and remained unchanged she remained in her collar until follow up with neurosurgery the patient resumed tube feedings via the gj tube she was re evaluated by speech and swallow service to determine if the patient could resume oral supplements the assessment could not be completed related to the patient s inability to follow instruction the foley catheter was removed and the patient was incontinent of urine the patient resumed anti coagulation medications with monitoring of attaining a goal of initial blood cultures grew staphylococcus coagulase negative but subsequent blood cultures reportedly showed no growth her sputum culture reportedly grew e coli and klebseilla and the patient transitioned to a course of augmentin last dose her repeat sputum culture on showed no micro organisms on the patient was reported to have diarrhea which was negative for c diff tube feeding changes were undertaken per recommendations of nutrition to help decrease the diarrhea in preparation for discharge the patient was evaluated by physical and occupational therapy and recommendations were made for discharge to a rehabilitation facility the patient was discharged on hd with stable vital signs her white blood cell count had normalized and her hematocrit remained stable at she was tolerating her tube feedings via the gj tube her inr at the time of discharge was appointments for follow up were made with the orthopedic neurosurgery and acute care surgery clinics medications on admission medications acetaminophen liquid mg po q6h prn pain mild acetylcysteine ml neb q4h prn mucus plugging artificial tear ointment appl both eyes prn dry eyes aspirin mg po daily bisacodyl mg pr qhs prn constipation chlorhexidine gluconate oral rinse ml oral bid glargine units breakfast glargine units bedtime insulin sc sliding scale using reg insulin ipratropium albuterol neb neb neb q6h levothyroxine sodium mcg po daily metoclopramide mg po qidachs metoprolol tartrate mg po bid milk of magnesia ml po q6h prn constipation nystatin oral suspension ml po qid prn thrush oxycodone liquid mg po q4h prn pain moderate pantoprazole mg po q24h ticagrelor mg po bid duration md to order daily dose po daily16 discharge medications acetaminophen mg po q6h prn pain mild acetylcysteine ml neb q4h prn mucous plugging amoxicillin clavulanate susp mg po q8h last dose artificial tear ointment appl both eyes prn dry eyes aspirin mg po daily bisacodyl mg pr qhs prn constipation insulin sc sliding scale fingerstick qachs insulin sc sliding scale using reg insulin ipratropium albuterol neb neb neb q6h lantus insulin glargine units subcutaneous bedtime lorazepam mg po q6h prn agitation metoclopramide mg po qidachs nystatin oral suspension ml po qid prn thrush oxycodone liquid mg po q8h prn pain moderate hold for increased sedation resp rate pantoprazole mg iv q24h warfarin mg po once duration dose insulin glargine subcutaneous breakfast levothyroxine sodium mcg po daily metoprolol tartrate mg po bid ticagrelor mg po bid md to order daily dose po daily16 daily dose based on daily discharge disposition extended care facility discharge diagnosis pneumonia 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 re admitted to the hospital from the rehabilitation center with fever and tachycardia you were also noted to have an elevated white blood cell count you underwent a cat scan and you were found to have pneumonia you were started on antibiotics your white blood cell count has normalized and you are preparing to return to the rehabilitation center to regain your strength and mobility you are being discharged 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 followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies compazine gadolinium containing contrast media attending chief complaint abdominal pain major surgical or invasive procedure eus history of present illness hpi mr is a male with h o ruq found to have a cbd stone s p ercp followed by ccy c b bile leak then s p repeat ercp with stent placement on he developed c diff which improved with vancomycin he then had the ercp stent removed on he was noted to have a friable cystic duct which was clipped during the initial procedure with removal of the stent he then developed abdominal pain and has had ruq pain along with pain radiating from the epigastrum to his chest since then he was hospitalized for persistent ruq pain from during which hida mrcp were performed and reportedly unrevealing he was trialed on gabapentin and tramadol which were ineffective and titrated off he underwent colonoscopy on revealing a cm semi sessile polyp tubular adenoma ercp on demonstrated mild duodenitis cystic duct stump cm long and focally dilated to mm possible containig a portion of the gb neck thought c w possible cytic duct remnant syndrome versus cystic duct mucocele the sphincterotomy was extended there as no evidence of bile leak scant sludge on ballon sweep he was then hospitalized for post ercp pancreatitis on he had a normal o p capsule endoscopy he was again admitted on to or acute pancreatitis with lipase wbc and ctap suggestive of uncomplicated pancreatitis the cause of his pancreatitis was not clear and was thought to not be secondary to a stone since his lfts were normal nor etoh nor on he had an exploaratory laparoscopy to directly assess the surgical site with no noted abnormalities to suggest a surgical cause of his pain he was hospitalized again from for acute pancreatitis with lipase tb alk p alt ast and wbc us was unrevealing he saw dr on where it was decided that he should undergo an eus he then returned home and was admitted the next day to in with worsening abdominal pain his pain is not worsened with eating it is worsened with breathing and moving it also worsened in the ambulance ride over to he had been able to eat a low fat diet in the ed his labs were unremarkable including normal lfts lipase and wbc count he was afebrile kub he was on dilaudid mg q hours receiving mg iv of dilaudid in hours with his pain improving to ketamine was initiated on and was discontinued because of sedation on he received iv zofran and ativan prn for nausea he was transferred to for eus as recommended by dr currently his pain is poorly controlled up to we discuss how to determine the cause of the pain and pain management wrt the cause he understands that dr has recommended eus wrt pain management he does not exist in or we agree to mg iv dilaudid q hour for doses max while pca is started he accepts this plan he had not had a bm for days or so but this is normal for him when he is admitted to the hospital he declines a bowel regimen he has lost unintentionally lost lbs since his surgery in he has a month old son and these frequent hospitalizations have meant that he has missed out on a lot of time with him ros pertinent positives and negatives as noted in the hpi all other systems were reviewed and are negative past medical history past medical history chronic gerd tubular adenoma of colon gerd pancreatitis cough epidermoid cyst of the skin cough fatigue h o difficulty sleeping obestiy rlq pain surgical history ercp stent removal ercp duct stent placement ccy ercp to remove duct calculi elbow arthrosopy surgery reattached tendon orthopedic surgery left elbow tendon repair ulnar repair ulnar nerve repair surgeries and social history family history mother with multiple sclerosis paranoid schizophrenia heart disease his father has htn his paternal gf had disease mgm had heart disease and died at age pgm had a malignant tumor breast and dm she died at age physical exam admission vitals temp po bp hr rr o2 sat o2 delivery 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 tenderness in the epigastric ruq mildly 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 discharge general man lying in hospital bed no apparent acute distress eyes perrl anicteric sclerae ent op clear cv rrr nl s1 s2 no m r g no jvd resp ctab no crackles wheezes or rhonchi gi hypoactive bs soft ttp diffusely but mostly in ruq and epigastrium nd voluntary guarding gu no suprapubic fullness or tenderness to palpation skin no rashes or ulcerations noted msk lower ext warm without edema neuro alert oriented to person place time situation face symmetric gaze conjugate with eomi speech fluent moves all limbs spontaneously no tremors asterixis or other involuntary movements observed psych pleasant appropriate affect pertinent results admission 59am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 59am blood glucose urean creat na k cl hco3 angap 59am blood alt ast alkphos amylase totbili 59am blood lipase 59am blood ctropnt 59am blood albumin calcium phos mg 59am blood triglyc discharge 34am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 34am blood glucose urean creat na k cl hco3 angap 34am blood calcium phos mg 05am blood igg subclasses within normal for all other notable lfts wnl albumin lipase trop trig igg subclasses pending labs lipase ca lipase amylase lipase lead with normal lipase lipase immunoglobulin g subclass hgba1c esr nml rf nml trig cea nml imaging eus successful upper eus evaluation as described above with evidence of chronic pancreatitis seen throughout the pancreatic parenchyma with combing and hyperechoic strands in the pancreatic body the parenchyma was hypoechoic suggestive of acute pancreatitis vs autoimmune pancreatitis cystic duct with area of shadowing which could represent air or surgical clips ekg nsr at bpm nl axis pr qrs qtc upsloping sub mm ste v2 v4 no prior for comparison kub osh normal gas pattern seen in small and large bowel loops there clips in the ruq from a ccy likely no other acute findings are noted no pathological calcifications lung bases are grossly clear brief hospital course man with hx gerd choledocholithiasis s p ercp and ccy c b bile leak requiring stent placement subsequently removed c diff multiple episodes of acute pancreatitis of unclear etiology and acute on chronic abdominal pain presenting as transfer from for further w u of abdominal pain found to have likely acute on chronic pancreatitis on of unclear etiology acute on chronic pancreatitis choledocholithiasis s p ccy c b bile leak developed ruq abdominal pain for which he was initially treated at underwent ercp with removal of cbd stone followed by ccy c b bile leak for which a stent was placed course was complicated by c diff stent was subsequently removed after which he developed recurrent ruq pain for which he has been hospitalized at multiple times for acute pancreatitis p showed uncomplicated pancreatitis with lipase extensive w u has been largely unrevealing hida and mrcp were reportedly nl ercp demonstrated mild duodenitis cystic duct stump cm long and focally dilated to mm possibly containing a portion of the gb neck thought c w possible cystic duct remnant syndrome versus cystic duct mucocele without e o bile leak capsule endoscopy nl multiple ultrasounds without e o stones ex laparoscopy to directly assess the ccy surgical site found no abnormalities to suggest a surgical cause of his pain not markedly elevated no significant etoh use igg previously nl nl he saw dr at on at which time plan was made for eus to evaluate for chronic pancreatitis or occult lesion prior to that study he re presented to with recurrent abdominal pain in the setting of nl lipase no imaging performed he was transferred to for further w u eus shows evidence of both acute and chronic pancreatitis possibly autoimmune mcrp with premedication due to allergy to gadolinium was done which didn t show evidence of autoimmune pancreatitis and igg subclasses also all normal he was gradually able to transition off the pca onto pregabalin onto pantoprazole and to a regular diet with pancrelipase enzymes with meals plan at discharge replace home famotidine with pantoprazole 40mg daily continue pregabalin 100mg bid continue oral hydromorphone 2mg prn breakthrough pain continue pancrelipase enzymes caps with each meal advanced endoscopy will set up with the patient in clinic patient instructed to set up pcp appointment in days 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 hyoscyamine mg po q8h prn pain hydromorphone dilaudid mg po q6h prn pain severe famotidine mg po bid discharge medications acetaminophen mg po q8h prn pain moderate pancrelipase cap po tid w meals rx lipase protease amylase zenpep unit unit unit tab cap by mouth three times a day before meals disp capsule refills pantoprazole mg po q24h rx pantoprazole mg tablet s by mouth once a day disp tablet refills polyethylene glycol g po daily pregabalin mg po bid rx pregabalin lyrica mg capsule s by mouth twice a day disp capsule refills senna mg po daily prn constipation first line hydromorphone dilaudid mg po q6h prn pain severe rx hydromorphone mg tablet s by mouth every six hours disp tablet refills discharge disposition home discharge diagnosis acute on chronic pancreatitis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr you were admitted to the hospital with abdominal pain an eus procedure was performed which showed evidence of both acute and chronic pancreatitis of unclear etiology you were treated with intravenous fluids pain medications and antinausea medications with resolution in your symptoms a mrcp was done which showed no evidence of autoimmune pancreatitis lab tests done to evaluate for this were also negative you are being discharged on pregabalin lyrica as well as oral hydromorphone dilaudid for if you need it you are also being discharged on pancrelipase enzymes to have with meals please contact your primary care doctor to set up a post discharge appointment ideally in the next days and gastroenterology here will be contacting you to set up a appointment with best wishes medicine followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies compazine gadolinium containing contrast media attending chief complaint abdominal pain major surgical or invasive procedure none history of present illness man with hx gerd choledocholithiasis s p ercp and ccy c b bile leak requiring stent placement subsequently removed c diff multiple episodes of pancreatitis presenting with significant abdominal pain and admitted for chronic pancreatitis flare he endorses two weeks of abdominal pain typically relieved by nighttime hydrocodone he presented to his local er in twice over the past two weeks treated with iv nausea and pain medications and subsequently discharged he presented to today because his pain has worsened over the past few days and he has run out of home po opiates he endorses ruq pain epigastric pain nausea and vomiting typical of his pancreatitis chart review shows he had cholecystectomy c b bile leak s p stent placement that was removed a month later after this he developed recurrent ruq pain and was hospitalized at multiple times for acute pancreatitis one time confirmed by ct a p other time lipase extensive workup including ex lap to assess surgical site unrevealing no known etiology of his pancreatitis eus showed acute and chronic pancreatitis possibly autoimmune though mrcp showed no evidence of autoimmune pancreatitis and igg levels normal in the ed initial vs were ra labs notable for normal cbc normal bmp normal lfts and normal lipase the patient received iv lr iv zofran x iv dilaudid x x and mg x he was seen by gi who recommended iv fluids iv zofran and iv pain control and admission to upon arrival to the floor the patient tells the story as follows he reports a two week worsening of his pain nausea and vomiting the vomiting is not typically of his pancreatitis flares he presented to and was given a prescription for hydrocodone acetaminophen which he has since run out of he ate breakfast yesterday but reports a decrease in appetite he denies fevers but endorses chills he reports that his pain has decreased to a but that he still has shooting intermittent pains he endorses some radiation to his chest which is typical for him and denies shortness of breath he has gained weight since his last discharge ros pertinent positives and negatives as noted in the hpi all other systems were reviewed and are negative past medical history past medical surgical history chronic gerd tubular adenoma of colon gerd pancreatitis cough epidermoid cyst of the skin cough fatigue h o difficulty sleeping obestiy rlq pain surgical history ercp stent removal ercp duct stent placement ccy ercp to remove duct calculi elbow arthrosopy surgery reattached tendon orthopedic surgery left elbow tendon repair ulnar repair ulnar nerve repair surgeries and social history family history mother with multiple sclerosis paranoid schizophrenia heart disease his father has htn his paternal gf had disease mgm had heart disease and died at age pgm had a malignant tumor breast and dm she died at age 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 mucous membranes dry cv heart regular no murmur resp lungs clear to auscultation with good air movement bilaterally gi abdomen soft non distended tender to palpation in the ruq and epigastric area no rebound or guarding msk neck supple moves all extremities strength grossly full and symmetric bilaterally in all limbs ext no edema skin no rashes or ulcerations noted neuro alert oriented face symmetric gaze conjugate with eomi speech fluent moves all limbs psych pleasant appropriate affect the patient was examined on day of discharge pertinent results admission significant labs 25pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 25pm blood glucose urean creat na k cl hco3 angap 25pm blood alt ast alkphos totbili micro none imaging other studies ct a p trace peripancreatic stranding and indistinctness of the pancreatic neck and head may suggest mild acute pancreatitis no evidence of fluid collection vascular injury or necrosis no other acute process in the abdomen pelvis normal appendix labs on discharge 15am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 15am blood glucose urean creat na k cl hco3 angap 15am blood alt ast alkphos totbili man with hx gerd choledocholithiasis s p ercp and ccy c b bile leak requiring stent placement subsequently removed c diff multiple episodes of pancreatitis presenting with significant abdominal pain and admitted for chronic pancreatitis flare recurrent acute on chronic pancreatitis flare unknown etiology of pancreatitis recent eus showed evidence of acute and chronic pancreatitis thought to be possibly autoimmune though igg levels were wnl he is followed by dr referred him recently to the pain management clinic where he was initiated on topiramate and amitryptyline on this admission ct a p obtained with findings consistent for acute pancreatitis without complications or other intraabdominal pathology he briefly required dilaudid pca for effective analgesia otherwise treated with ivf and bowel rest ultimately able to advance diet to regular with resumption of pancreatic enzymes seen by pain team with plans to expedite follow up for evaluation to receive celiac plexus block in addition to ongoing follow up with dr his pain doctor recommend ongoing outpatient therapy for stress management gerd continued omeprazole mg daily mins spent on coordinating discharge medications on admission the preadmission medication list is accurate and complete amitriptyline mg po qhs pantoprazole mg po q24h zenpep lipase protease amylase unit oral daily topiramate topamax mg po daily hydrocodone acetaminophen mg oral q6h prn pain discharge medications amitriptyline mg po qhs hydrocodone acetaminophen mg oral q6h prn pain pantoprazole mg po q24h topiramate topamax mg po daily zenpep lipase protease amylase unit oral daily discharge disposition home discharge diagnosis acute on chronic pancreatitis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr it was a privilege to care for you at the you were admitted with a flare of your pancreatitis requiring iv pain medications hydration and bowel rest your symptoms have improved and it is now safe for you to be discharged continue to take all other medications as prescribed and make sure you follow up with all appointments as detailed below 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 compazine gadolinium containing contrast media attending chief complaint progressive recurrent abdominal pain major surgical or invasive procedure celiac plexus block history of present illness with hx of gerd choledocholithiasis s p ercp and ccy c b bile leak requiring stent placement subsequently removed c diff multiple episodes of recurrent pancreatitis admitted with recurrent abdominal pain presenting with recurrent abdominal pain reminiscent of prior episodes of pancreatitis pt describes onset of ruq pain that radiates to his back starting on progressive despite home medications he endorses associated anorexia denies f c chest pain diarrhea melena hematochezia pain is the same as prior episodes he notes that evaluation at dr prior to presenting to the ed included an abdominal exam that escalated his pain although is also appropriately understanding of the need for serial abdominal exams pt reports that when he left the hospital on he was in pain ruq and epigastrium intermittently sharp and hard throbbing pain as it escalates from to it typically migrates from ruq more towards the epigastrium he does not add otc medications during acute episodes he uses hydrocodone apap at home which is prescribed q6h prn but he only takes at night he endorses nausea without emesis he denies diarrhea constipation denies headaches sob he does get chest pain that is actually radiating epigastric pain radiates up through r chest he has been followed by pain service as outpatient and is undergoing evaluation for celiac plexus block as part of that evaluation plan was for u s guided injection into abdominal muscles on to rule out abdominal wall pain pt was seen by dr on based on dr from that visit potential etiologies for his chronic pain with intermittent flares include gallstones within remnant gallbladder postcholecystectomy syndrome plan per dr note is to review pt s case at pancreaticobiliary multidisciplinary management conference on in the ed vs ra exam notable for general no acute distress heent normal oropharynx no exudates erythema cardiac rrr no chest tenderness pulmonary clear to auscultation bilaterally with good aeration no crackles wheezes abdominal gi right upper quadrant tenderness to palpation soft nondistended renal no cva tenderness msk no deformities or signs of trauma no focal deficits noted neuro sensation intact upper and lower extremities strength upper and lower no focal deficits noted moving all extremities labs notable for wbc hb plt cr lfts wnl lipase inr imaging ruq u s no evidence of biliary ductal stone or obstruction mild pneumobilia previously seen on prior ct dated nonvisualization of the pancreas consults none received dilaudid mg iv x2 zofran mg iv x2 ivf on arrival to the floor pt reports pain with nausea past medical history past medical surgical history chronic gerd tubular adenoma of colon gerd pancreatitis cough epidermoid cyst of the skin cough fatigue h o difficulty sleeping obestiy rlq pain surgical history ercp stent removal ercp duct stent placement ccy ercp to remove duct calculi elbow arthrosopy surgery reattached tendon orthopedic surgery left elbow tendon repair ulnar repair ulnar nerve repair surgeries social history family history mother with multiple sclerosis paranoid schizophrenia heart disease his father has htn his paternal gf had disease had heart disease and died at age pgm had a malignant tumor breast and dm she died at age physical exam gen alert and interactive no acute distress heent anicteric sclera face mildly flushed lungs non labored breathing gi soft mild tenderness in epigastrium normal active bowel sounds extremities no edema skin no new rashes skin warm neuro alert and interactive speech fluent psych normal mood and affect pertinent results 08pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 10am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 08pm blood plt 10am blood 11pm blood urean creat na k cl hco3 angap 10am blood glucose urean creat na k cl hco3 angap 11pm blood alt ast alkphos amylase totbili 10am blood alt ast alkphos totbili 18am blood triglyc hdl chol hd ldlcalc 18am blood calcium phos mg cholest mrcp w secretin findings suggestive of chronic pancreatitis with decreased normal intrinsic t1 hyperintensity of the pancreas mm dilated side branch in the pancreatic body and decreased compliance of the pancreatic duct post secretin administration no findings to suggest main pancreatic duct stricturing or findings to suggest papillary stenosis pancreatic duct orifice stenosis post secretin administration no evidence of acute pancreatitis pancreatic necrosis or peripancreatic collection pancreatic fluid is secreted into the second portion of the duodenum after secretin administration with evaluation of passage of this fluid past the genu limited by pre existing fluid within small bowel loops which overlap the duodenum mild splenomegaly and trace bilateral pleural effusions brief hospital course with hx of gerd choledocholithiasis s p ercp and ccy c b bile leak requiring stent placement subsequently removed c diff multiple episodes of recurrent pancreatitis presenting with acute on chronic pain in the setting of chronic pancreatitis acute on chronic ruq epigastric pain chronic pancreatitis ptsd previous eus and now mrcp with signs of chronic pancreatitis though his symptoms are such that chronic pancreatitis would not make since as a sole etiology other possible contributions include postcholecystectomy pain syndrome and visceral hyperalgesia a history of trauma is likely also impacting his current experience and his interpretation of pain opioid tolerance and hyperalgesia may also be playing a roll weaned opioids to hydromorphone po mg q hours as needed has been following with dr to re schedule his therapy intake genetic testing for chronic pancreatitis ambry genetics pending increased home amitriptyline to mg qhs continue home tizanidine topiramate and zenpep the was seen and examined on the day of discharge the total time spent preparing discharge was minutes medications on admission the preadmission medication list is accurate and complete amitriptyline mg po qhs pantoprazole mg po q24h topiramate topamax mg po daily hydrocodone acetaminophen mg oral q6h prn pain zenpep lipase protease amylase unit oral daily tizanidine mg po qhs prn pain discharge medications acetaminophen mg po q8h hydromorphone dilaudid mg po q4h rx hydromorphone mg tablet s by mouth every hours as needed disp tablet refills polyethylene glycol g po daily rx polyethylene glycol gram dose by mouth once a day disp packet refills senna mg po qhs rx sennosides mg tab by mouth once a day disp tablet refills amitriptyline mg po qhs rx amitriptyline mg tablet s by mouth once a day disp tablet refills pantoprazole mg po q24h tizanidine mg po qhs prn pain topiramate topamax mg po daily zenpep lipase protease amylase unit oral daily discharge disposition home discharge diagnosis chronic pancreatitis postcholecystectomy pain syndrome visceral hyperalgesia discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions mr you were seen at for abdominal pain we performed a celiac plexus block and adjusted your medications to help with this followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies compazine gadolinium containing contrast media attending major surgical or invasive procedure rectus sheath block performed by anesthesia endoscopy with ultrasound guided celiac plexus block performed by advanced endoscopy team attach pertinent results admission labs 45am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 45am blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 45am blood glucose urean creat na k cl hco3 angap 45am blood alt ast alkphos totbili dirbili indbili 45am blood albumin 45am blood lactate discharge labs n a imaging ruq u s findings limited evaluation due to acoustic shadowing from overlying bowel gas within this limitation liver the right hepatic lobe parenchyma appears within normal limits the left hepatic lobe is not very well visualized the contour of the liver is smooth there is no focal liver mass the main portal vein is patent with hepatopetal flow there is no ascites bile ducts there is no intrahepatic biliary dilation chd mm gallbladder the patient is status post cholecystectomy pancreas the pancreas is not well visualized largely obscured by overlying bowel gas spleen normal echogenicity spleen length cm kidneys limited views of the right kidney shows no hydronephrosis retroperitoneum the visualized portions of aorta and ivc are within normal limits impression pancreas and left hepatic lobe are not visualized due poor acoustic shadowing no biliary ductal dilatation in the right hepatic lobe patent main portal vein endoscopic ultrasound w celiac plexus block see report for details micro patient had bout of loose stools on which resolved without further intervention and did not recur stool sample was sent and infectious studies have been negative thus far with only the giardia cryptospora stool dfa pending for which we have very low ongoing suspicion 13pm stool cdifpcr neg pm stool consistency not applicable source stool fecal culture final no salmonella or shigella found campylobacter culture final no campylobacter found ova parasites final no ova and parasites seen this test does not reliably detect cryptosporidium cyclospora or microsporidium while most cases of giardia are detected by routine o p the giardia antigen test may enhance detection when organisms are rare fecal culture r o vibrio final no vibrio found fecal culture r o yersinia final no yersinia found fecal culture r o e coli h7 final no e coli o157 h7 found cryptosporidium giardia dfa pending brief hospital course mr presented with acute worsening of chronic right upper quadrant with epigastric vs were normal and stable on presentation labs were unremarkable and remained stable he was treated with oral medications and his remained stable he was evaluated by the anesthesia service with whom he has previously followed up in clinic and they recommended celiac plexus block he underwent a rectus sheath abdominal wall injection on performed by the anesthesia team which did not significantly improve the the advanced gi endoscopy team performed an endoscopy with ultrasound guided celiac plexus block on which was successful he was reporting abdominal discomfort but not really on the day of discharge following breakfast a substantial improvement from the he was experiencing prior to the celiac plexus block he was tolerating a regular diet and oral medications throughout his hospital course as well as on the day of discharge of note he consistently refused heparin sc for vte ppx as well as a bowel regimen to prevent and treat opioid induced constipation which he experienced despite counseling during this hospitalization he was not provided with any new prescriptions for opioid medications upon discharge time in care minutes in discharge related activities today medications on admission the preadmission medication list is accurate and complete amitriptyline mg po qhs pantoprazole mg po q24h tizanidine mg po qhs prn topiramate topamax mg po daily acetaminophen mg po q8h zenpep lipase protease amylase unit oral daily senna mg po qhs polyethylene glycol g po daily hydromorphone dilaudid mg po q4h discharge medications acetaminophen mg po q8h amitriptyline mg po qhs hydrocodone acetaminophen 5mg 325mg tab po q4h prn severe pantoprazole mg po q24h polyethylene glycol g po daily hold for bms in past hours senna mg po qhs hold if bms in past hours tizanidine mg po qhs prn do not drive or operate heavy machinery within hours of taking this medication zenpep lipase protease amylase unit oral daily discharge disposition home discharge diagnosis acute worsening of chronic ruq epigastric discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions mr you presented to the hospital with worsening in your right upper abdomen and epigastric region you were evaluated by the anesthesia specialists who felt that pursuing a repeat celiac plexus nerve block was a reasonable next step to get your under better control but unfortunately that procedure would not be available until after the holiday weekend you underwent a rectus sheath abdominal wall injection on performed by the anesthesia team which did not significantly improve the yesterday on you underwent an endoscopy with ultrasound guided celiac plexus block performed by the advanced gi endoscopy team you were able to tolerate an regular diet and oral medications so you are being discharged home today and we recommend that you contact dr office to schedule a follow up appointment please also plan to follow up with dr in the gi clinic at your next scheduled appointment to continue the ongoing evaluation for your abdominal and chronic pancreatitis we wish you the best sincerely your medicine team followup instructions

name unit no admission date discharge date date of birth sex f service surgery allergies aspirin duragesic sulfa sulfonamide antibiotics erythromycin base penicillins flagyl attending chief complaint left leg pain major surgical or invasive procedure left common femoral artery endarterectomy history of present illness this patient is a woman with a history of progressive left leg ischemia with intermittent rest pain last week she was taken to the angiography suite where she was found to have a left common femoral high grade stenosis and a left sfa occlusion i decided to proceed with left sfa intervention prior to treating inflow disease we performed the sfa stenting and sent her home for several days and she is now back for her inflow procedure i am doing this primarily to improve perfusion and maintain stent patency the procedure and risks were explained to her and her sister they understood and wished to proceed past medical history htn migraines takes fioricet multiple times a day ibs oa seizure disorder gerd depression borderline personality d o narcotic abuse has port a cath for ivf for chronic ileus per patient social history family history nc physical exam vitals avss see flowsheets gen nad pleasant conversant resp no increased work of breathing clear to auscultation bilaterally cv rrr abd soft non tender non distended wound left groin incision is clean and intact with minimal serosanguinous drainage extremities warm well perfused pulse exam r pfem ppop ddp dpt l p p d d pertinent results 40am urine hours random 40am urine gr hold hold 40am urine color straw appear clear sp 40am urine blood neg nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk lg 40am urine rbc wbc bacteria few yeast none epi trans epi 40am urine amorph rare brief hospital course is a year old woman left lower extremity rest pain recently s p angio showing l cfa stenosis and l sfa stenosis s p pta stent on who was admitted to the on the patient was taken to the endovascular suite and underwent a left common femoral artery endarterectomy for details of the procedure please see the surgeon s operative note the patient tolerated the procedure well without complications and was brought to the post anesthesia care unit in stable condition after a brief stay the patient was transferred to the vascular surgery floor where she remained through the rest of the hospitalization post operatively she did well without any groin swelling she did have incisional pain on post operative day and her pain regimen was titrated accordingly she was able to tolerate a regular diet get out of bed and ambulate with assistance of staff for support void without issues and pain was controlled on oral medications alone by pod she was deemed ready for discharge to a rehabilitation facility she was given the appropriate discharge and follow up instructions medications on admission the preadmission medication list is accurate and complete acetaminophen mg po q6h prn pain mild lisinopril mg po daily gabapentin mg po tid dicyclomine mg po bid propranolol la mg po daily atorvastatin mg po qpm multivitamins tab po daily perphenazine mg po daily pantoprazole mg po q24h fluoxetine mg po daily cyanocobalamin mcg po daily discharge medications clopidogrel mg po daily rx clopidogrel mg tablet s by mouth daily disp tablet refills docusate sodium mg po bid hold for loose or frequent stool ondansetron odt mg sl q8h prn nausea rx ondansetron mg tablet s by mouth q8h prn disp tablet refills oxycodone immediate release mg po q4h prn pain rx oxycodone mg tablet s by mouth q4h prn disp tablet refills senna mg po bid prn constipation acetaminophen mg po q8h atorvastatin mg po qpm cyanocobalamin mcg po daily dicyclomine mg po bid fluoxetine mg po daily gabapentin mg po tid lisinopril mg po daily multivitamins tab po daily pantoprazole mg po q24h perphenazine mg po daily propranolol la mg po daily discharge disposition extended care facility discharge diagnosis peripheral vascular disease discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms you were admitted to for surgery to improve the blood flow to your left leg you underwent a left cfa endarterectomy you have recovered well and are now ready for discharge home please follow the instructions below regarding your care to ensure a speedy recovery medication if instructed take plavix clopidogrel 75mg once daily for days then take aspirin daily continue all other medications you were taking before surgery unless otherwise directed you make take tylenol or prescribed pain medications for any post procedure pain or discomfort what to expect it is normal to have slight swelling of the legs elevate your leg above the level of your heart with pillows every hours throughout the day and night avoid prolonged periods of standing or sitting without your legs elevated it is normal to feel tired and have a decreased appetite your appetite will return with time drink plenty of fluids and eat small frequent meals it is important to eat nutritious food options high fiber lean meats vegetables fruits low fat low cholesterol to maintain your strength and assist in wound healing to avoid constipation eat a high fiber diet and use stool softener while taking pain medication activities no driving until post op visit and you are no longer taking pain medications unless you were told not to bear any weight on operative foot you should get up every day get dressed and walk you should gradually increase your activity you may up and down stairs go outside and or ride in a car increase your activities as you can tolerate do not do too much right away no heavy lifting pushing or pulling greater than pounds until your post op visit you may shower unless you have stitches or foot incisions no direct spray on incision let the soapy water run over incision rinse and pat dry your incision may be left uncovered unless you have small amounts of drainage from the wound then place a dry dressing over the area that is draining as needed call the office for redness that extends away from your incision a sudden increase in pain that is not controlled with pain medication a sudden change in the ability to move or use your leg or the ability to feel your leg temperature greater than 5f for hours bleeding new or increased drainage from incision or white yellow or green drainage from incisions thank you for allowing us to participate in your medical care sincerely your surgery team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies aspirin duragesic sulfa sulfonamide antibiotics erythromycin base penicillins flagyl attending chief complaint left groin pain at incision site for days major surgical or invasive procedure none history of present illness s p left common femoral endarterectomy with dr with complain of left groin pain at incision site for days found on osh ct scan currently unavailable to have reported cm collection superficial to cfa the patient states she has had days of left groin pain that is causing her to go to her pcp her pcp obtained ct scan which revealed the fluid collection she came to ed after learning the results the scans are not currently available due to a tech issue she reports taking her plavix as prescribed scheduled to stop next day after admission she denies numbness or tingling in either lower extremity extremities are wwp and denies cp sob ha and all other symptoms past medical history htn migraines takes fioricet multiple times a day ibs oa seizure disorder gerd depression borderline personality d o narcotic abuse had port a cath for ivf for chronic ileus per patient social history family history nc physical exam admission physical exam vitals t bp hr rr o2sat ra gen a o nad heent no scleral icterus mucus membranes moist cv rrr no m g r pulm non labored respirations on ra abd soft nondistended focal mild ttp llq no rebound or guarding normoactive bowel sounds no palpable masses left groin incision well healed extremities warm and well perfused neuro a ox3 discharge physical exam vs af 140s 70s 60s ra i o general nad resting comfortably a o to hospital year self heent at nc heart rrr s1 s2 no murmurs gallops or rubs lungs ctab no wheezes rales rhonchi abdomen mildly tender in llq bs extremities site of l femoral endarterectomy appears c d i without tenderness or erythema no cyanosis clubbing or edema moving all extremities with purpose neuro cn ii xii grossly intact except baseline l sided facial droop moving all extremities with purpose dowb intact skin warm and well perfused no excoriations or lesions no rashes pertinent results admission labs 15am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 15am blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 15am blood ptt 15am blood glucose urean creat na k cl hco3 angap 00am blood calcium phos mg 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 imaging ct abd pelv limited examination without iv contrast no imaging findings to explain left lower quadrant pain while there is mild thickening of the sigmoid colonic wall and equivocal adjacent fat stranding this is a fairly similar appearance to the prior ct from and likely related to muscular hypertrophy related to chronic diverticular disease small amount of fat stranding in fluid density in the left groin region likely represent sequelae from prior intervention please correlate with any prior recent interventions to the left groin persistent dilation of the right renal collecting system lle u s a2 x x cm irregular fluid collection with internal debris could represent abscess versus hematoma surrounding soft tissue edema favors abscess comparison can be made if prior imaging becomes available brief hospital course s p left common femoral endarterectomy who s presenting with days of pain found to likely have small hematoma at site of recent endarterectomy with leukocytosis to initially concerning for abscess but found to have possible diverticulitis on ct scan which improved with antibiotics diverticulitis leukocytosis patient with elevated wbc and llq abdominal pain initially thought abscess at l femoral site per vascular surgery however ct scan unremarkable for infection at site but did reveal sigmoid thickening initially concerning for diverticulitis on preliminary read but then later final read thought this was less likely ua cx ngtd bcx ngtd cxr unremarkable no other signs of infection elsewhere patient was initially treated with vanco cipro flagyl note that per chart she has a flagyl allergy but pt denies this and she tolerated flagyl well which was narrowed to cipro flagyl only with improvement in leukocytosis and abdominal pain she will complete day course of abx last day patient was continued on bowel regimen and pain controlled with oxycodone initially 10mg q4h downtitrated to 5mg q4h on discharge tolerating solid po diet on discharge she should have a colonoscopy weeks after discharge peripheral vascular disease s p left common femoral endarterectomy patient continued on plavix and statin normally would transition to asa 81mg days after vascular procedure however patient with aspirin allergy recommend continuing plavix until follow up with vascular in month after discharge abdominal pain continued home dicyclomine and zofran treated diverticulitis as above htn continued home lisinopril and propranolol history psych disorders continued home perphenazine 4mg and fluoxetine 40mg gerd continued home pantoprazole disposition inability to care for self as per social history patient had been living with a roommate who was also not very good at self care but together the two of them compensated for each other per her sister and her case manager since the roommate died the patient has had poor self care due to chronic cognitive weakness namely not eating not being able to do adls and at one point getting lost outside in the winter was seen by who found she had impaired orientation memory safety awareness sister had been working on a bed at a facility and patient was amenable to go there on discharge so hcp did not need to be invoked for billing purposes only minutes spent on patient care and coordination transitional issues continue ciprofloxacin and flagyl to complete day course of abx last day recommend colonoscopy weeks after discharge please titrate off oxycodone as was only started for abdominal pain on admission recommend allergy appt as outpatient as has multiple unknown allergies including penicillin sulfas pt with aspirin allergy she will continue on plavix until follow up with vascular surgery she should have duplex of her lle and follow up with dr month after discharge please call to receive this followup appointment as it is currently pending medications on admission the preadmission medication list is accurate and complete atorvastatin mg po qpm clopidogrel mg po daily dicyclomine mg po bid fluoxetine mg po daily gabapentin mg po tid lisinopril mg po daily ondansetron dose is unknown po frequency is unknown pantoprazole mg po q24h perphenazine mg po once propranolol la mg po daily acetaminophen mg po q6h prn pain mild cyanocobalamin mcg po daily centrum silver men multivit min fa lycopen lutein mg mcg mcg oral daily discharge medications ciprofloxacin hcl mg po q12h metronidazole mg po q8h oxycodone immediate release mg po q4h prn pain moderate rx oxycodone mg capsule s by mouth every four hours disp capsule refills polyethylene glycol g po daily prn constipation senna mg po hs acetaminophen mg po tid ondansetron odt mg po q8h prn nausea atorvastatin mg po qpm centrum silver men multivit min fa lycopen lutein mg mcg mcg oral daily clopidogrel mg po daily cyanocobalamin mcg po daily dicyclomine mg po bid fluoxetine mg po daily gabapentin mg po tid lisinopril mg po daily pantoprazole mg po q24h perphenazine mg po daily propranolol la mg po daily discharge disposition extended care facility discharge diagnosis primary diverticulitis secondary hypertension psychiatric disorders peripheral vascular disease s p left common femoral endarterectomy discharge condition mental status confused sometimes level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear ms it was a pleasure taking care of you why you were admitted you were admitted because you were having abdominal pain what we did for you you were found to have an infection in your bowel can diverticulitis you were treated with antibiotics with improvement the occupational therapist recommended that you go to rehab what should you do when you leave the hospital please continue taking all your medications please continue taking your antibiotics ciprofloxacin metronidazole to complete a day course last day please attend your follow up appointments you should receive a call from the vascular surgery clinic regarding an appointment with dr to be scheduled in month after discharge if you do not hear back within days please call we wish you the best your team followup instructions