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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain and right eye blurry vision
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old lady with lupus anticoagulant,
history of recurrent PE (___), and long-standing
anxiety/panic attacks currently on coumadin who presents today
with 1.5 days of chest pain acutely worsening today accompanied
by monocular blurry vision out of the right eye.
As per Ms. ___, she has been having intermittent chest pains
___ times/week for the last month. Pain occurs when she takes a
shallow breath and then worsens when she takes a deep breath. It
usually resolves in 5 minutes and rated ___. However, 2 days
ago she developed this usual pain but it took about 30min to
resolve. There was associated tenderness to palpation under her
left breast and she felt a lump as well. There was no inciting
factor. The following day she again had the same event. Today,
she had no pain at all AM, and as per her PCP's recommendations
underwent a mammogram this afternoon. A few minutes after the
mammogram, she developed intense chest pain that felt like a
deep pain (she describes it as intermittent like "labor pains").
This then became a crushing, pressure like pain like "someone
sat on her chest." This now radiated to her right scapula and
her back and rated ___.
Along with this disabling chest pain she developed blurry vision
out of her right eye. She presented to the ER where her NIHSS=0
but she was noted to have weakness of right hand grip. She
denies any diplopia, or any vision changes out of the left eye.
She endorses photophobia in the right eye, right periorbital
pressure, as well as a migraine like headache in her left
forehead. As per her, her most recent INR was 2.6.
On neuro ROS, the patient endorses headache, and blurred vision
from R eye as well as photophoba in that eye. Denies diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the patient endorses night sweats,
chest pain and palpiations. Denies recent fever or chills. No
recent weight loss or gain. Denies cough, shortness of breath.
Denies nausea, vomiting, diarrhea, constipation or abdominal
pain. No recent change in bowel or bladder habits. No dysuria.
Denies arthralgias or myalgias. Psoriatic rash on lateral left
thigh.
Past Medical History:
Lupus anticoagulant positive
Recurrent pulmonary embolism, (___)
Hypothyroidism
Psoriasis
Panic attacks
Anxiety
PSHx:
Emergency C-section ___
Social History:
___
Family History:
Multiple PE events on both sides of the family. Mother died from
PE. Father still alive and recently had an MI. Paternal uncle
died from complications of DMII. No history of cancer in the
family.
Physical Exam:
ADMISSION EXAM:
Vitals: T:97.4 P:86 R: 24 BP:126/90 SaO2: 98% 3L NC
General: Awake, cooperative, NAD.
HEENT: NC/AT MMM, no lesions noted in oropharynx. R conjunctival
injection.
Neck: Supple. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl.
Abdomen: soft, NT/ND.
Extremities: Warm and well perfused
Skin: Large, erthematous scaly plaques on thighs.
-----------
Neurologic:
-----------
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to read without difficulty from left eye but has difficulty with
right eye. Speech was not dysarthric. Able to follow both
midline and appendicular commands. The pt had good knowledge of
current events. There was no evidence of apraxia or neglect.
-Cranial Nerves:
II: visual acuity ___ out of left eye but ___ out of right
eye. PERRL 2.5mm to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades. Pain
behind right eye on EOM.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact grossly
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Mild right drift but no
pronation.
Delt Bic Tri WrE FE FFl IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5
R 5 ___ 5- ___ 5 5 5
-Sensory: No deficits to light touch or cold sensation
throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was mute bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
---------------
Ophthalmologic:
---------------
Visual Acuity;
OD (sc): ___ ph ___
OS (sc): ___
Pupils (mm)
Relative afferent pupillary defect: [x] none [ ] present
OD: ___
OS: ___
Extraocular motility: Full ___
Visual fields by confrontation: Full to counting fingers ___
Color Vision (___ pseudo-isochromatic plates):
OD: ___
OS: ___
No red desat
Intraocular pressure (mm Hg):
OD: 8
OS: 8
External Exam: [x ] NL
Anterior Segment (portable slitlamp)
Lids/Lashes/Lacrimal:
OD: Normal
OS: Normal
Conjunctiva:
OD: tr injection
OS: tr injection
Cornea:
OD: Clear, no epithelial defects
OS: Clear, no epithelial defects
Anterior Chamber:
OD: Deep and quiet
OS: Deep and quiet
___:
OD: Flat
OS: Flat
Lens:
OD: Clear
OS: Clear
Fundus (Indirect Ophthalmoscopy using 20D lens): Dilation
approved by BI ER team
PLEASE NOTE, PUPILS WILL REMAIN DILATED FOR AT LEAST ___ HRS
Media/Vitreous:
OD: Clear
OS: Clear
Discs:
OD: pink, sharp margins 0.2
OS: pink, sharp margins ___
Maculae:
OD: flat, normal foveal light reflex, no emboli seen
OS: flat, normal foveal light reflex, cotton wool spot along
inferior arcade, no emboli seen
Periphery
OD: no heme, breaks or other notable lesions
OS: no heme, breaks or other notable lesions
DISCHARGE EXAM:
Unchanged from above except:
No pupillary abnormalities, red supersaturation in the right eye
(appears purple)
Pertinent Results:
___ 11:50AM GLUCOSE-123* UREA N-10 CREAT-0.7 SODIUM-137
POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-24 ANION GAP-15
___ 12:07PM URINE UCG-NEGATIVE
___ 11:50AM CALCIUM-8.2* PHOSPHATE-2.7 MAGNESIUM-2.1
___ 11:50AM WBC-4.0 RBC-3.57* HGB-11.9* HCT-36.3 MCV-102*
MCH-33.5* MCHC-32.9 RDW-14.0
___ 09:56AM ___ PTT-30.9 ___
___ 02:10AM cTropnT-<0.01
___ 07:33PM LACTATE-3.1*
___ 07:30PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 07:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-MOD
___ 07:30PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-5
___ 07:15PM ALT(SGPT)-13 AST(SGOT)-21 ALK PHOS-32* TOT
BILI-0.8
___ 07:15PM cTropnT-<0.01
___ 07:15PM ___ PTT-31.6 ___
IMAGING
***
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 2 mg PO DAILY16
2. Levothyroxine Sodium 200 mcg PO DAILY
3. Prenatal Vitamins 1 TAB PO DAILY
4. Ketoconazole 2% 1 Appl TP BID
5. Fluocinonide 0.05% Ointment 1 Appl TP BID
6. Desonide 0.05% Cream 1 Appl TP BID PRN skin irritation
Discharge Medications:
1. Levothyroxine Sodium 200 mcg PO DAILY
2. Warfarin 7 mg PO 3X/WEEK ___, T, Th
3. Warfarin 6 mg PO 4X/WEEK (___)
4. ALPRAZolam 0.5 mg PO BID:PRN anxiety
RX *alprazolam 0.5 mg 1 tablet(s) by mouth twice a day Disp #*10
Tablet Refills:*0
5. ClonazePAM 0.5 mg PO BID
RX *clonazepam 0.5 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
6. Sertraline 25 mg PO DAILY
RX *sertraline 25 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
7. Desonide 0.05% Cream 1 Appl TP BID PRN skin irritation
8. Fluocinonide 0.05% Ointment 1 Appl TP BID
9. Ketoconazole 2% 1 Appl TP BID
10. Prenatal Vitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Eye pain, blurry vision, chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI BRAIN AND ORBITS
INDICATION: ___ year old woman with new onset blurry vision // assess for
inflammatory lesions
TECHNIQUE: Multisequence, multiplanar MRI of the brain and orbits with and
without intravenous gadolinium.
COMPARISON: CTA head ___.
FINDINGS:
There is no evidence of acute intracranial hemorrhage or mass effect. The
ventricles and basal cisterns appear normal.
There is no evidence of acute ischemia based on diffusion-weighted imaging.
The brain parenchymal volume is within normal limits. There are normal
vascular flow voids. There is no abnormal brain parenchymal or leptomeningeal
enhancement.
The globes are intact. The optic nerves are symmetric without abnormal
enhancement. The extraocular muscles appear normal in size. The optic chiasm
appears normal.
The skull base and paranasal sinuses appear unremarkable.
IMPRESSION:
Normal MRI of the brain and orbits.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Chest pain, Dyspnea, Anxiety
Diagnosed with CHEST PAIN NOS, VISUAL DISTURBANCES NEC, LONG TERM USE ANTIGOAGULANT
temperature: 97.4
heartrate: 86.0
resprate: 24.0
o2sat: 98.0
sbp: 126.0
dbp: 90.0
level of pain: 6
level of acuity: 2.0 | Dear Ms. ___,
You were admitted to ___ for symptoms of blurry vision and
right eye pain as well as chest pain. Ophthalmology evaluated
your eye and determined that there were no vascular
abnormalities. You had an MRI of your brain and orbit which
showed ****. You had a full cardiac workup in the ED which
included troponins (enzymes which are elevated when your heart
has damage) and an EKG (which assesses the electrical signals
that drive your heart to beat). All the tests were normal. You
have a history of panic attacks and anxiety which contribute a
lot to your episodes of chest pain. We started you on some
medications to help you cope with your anxiety including
Klonodine 0.5mg BID and Sertraline 25mg Qday. We also prescribed
you Xanax 0.5mg to take as needed for anxiety attacks. We
recommend you follow up with your primary care provider to help
you manage your stress and anxiety. An appointment has been
scheduled for you. It was a pleasure caring for you during your
stay.
Dear Ms. ___,
You were admitted to ___ for symptoms of blurry vision and
right eye pain as well as chest pain. Ophthalmology evaluated
your eye and determined that there were no vascular
abnormalities. You had an MRI of your brain and orbit which
showed no abnormalities. You had a full cardiac workup in the ED
which included troponins (enzymes which are elevated when your
heart has damage) and an EKG (which assesses the electrical
signals that drive your heart to beat). All the tests were
normal. You have a history of panic attacks and anxiety which
may contribute to your episodes of chest pain. We started you on
some medications to help you cope with your anxiety including
Klonodine 0.5mg BID and Sertraline 25mg Qday. We also prescribed
you Xanax 0.5mg to take as needed for anxiety attacks. We
recommend you follow up with your primary care provider to help
you manage your stress and anxiety. An appointment has been
scheduled for you. It was a pleasure caring for you during your
stay.
Dear Ms. ___,
You were admitted to ___ for symptoms of blurry vision and
right eye pain that started in the Emergency Room where you had
presented for evaluation of chest pain. Ophthalmology evaluated
your eye and determined that there were no vascular
abnormalities. You had an MRI of your brain and orbit which
showed no abnormalities. You had a full cardiac workup in the ED
which included troponins (enzymes which are elevated when your
heart has damage) and an EKG (which assesses the electrical
signals that drive your heart to beat). All the tests were
normal.
You have a history of panic attacks and anxiety which may
contribute to your episodes of chest pain. We started you on
medication to help cope with your anxiety including Sertraline
25mg daily (for anxiety) and Lorazepam 0.5mg daily as needed for
panic attacks. We recommend you follow up with your primary care
provider to help you manage your stress and anxiety. An
appointment has been scheduled for you.
We also found that your hypothyroidism has worsened
significantly since you stopped taking your Levothyroxine. You
should resume this medication on a daily basis on discharge.
It is also very important that you take your Coumadin daily, as
prescribed. You should STOP eating large amounts of leafy greens
in your diet, as these can interfere with your Coumadin levels
and result in a lower INR. Your INR was 1 on the day of
discharge -- you have emailed your PCP and should plan on
discussing a dose increase tomorrow.
It was a pleasure caring for you during your stay. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
nasal spray
Attending: ___
Chief Complaint:
pleuritic chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ year old man with a history of complete heart
block s/p pacemaker, hyperlipidemia, hypertension, mitral valve
prolapse s/p MVR ___, OSA, possible SIADH, recently admitted
for respiratory failure due to CHF and severe MR, discharged to
rehab, presenting with one day of pleuritic bilateral chest pain
and dyspnea.
Briefly, he was admitted from ___ to ___ after requiring
intubation for respiratory failure related to CHF and severe
mitral regurgitation. Had acute renal failure in setting of
attempted diuresis so required CVVH for fluid removal. Multiple
extubation attempts failed due to recurrent flash pulmonary
edema on zero-PEEP trials, and he was treated with broad
spectrum abx for potential pneumonia, with eventually negative
bronch/infectious work-up. IABP was placed ___ for afterload
reduction. On ___ had MV repair with P2 triangular resection
and annuloplasty, and b/l drainage of pleural effusions.
Post-operatively, he again failed trial of extubation. Then had
R sided PTX requiring pigtail & eventually required VATS in
setting of acute Hct drop & RUL infiltrate w/ evacuation of
hematoma on ___. Extubated on ___. Also noted to be somnolent
and confused w/ neg head CT & EEG showing evidence of
encephalopathy. CCU course also complicated by persistent
fevers, attributed to cefepime (fevers stopped once cefepime
switched to zosyn). He was discharged on intermittent
hemodialysis via a temporary line, which was discontinued while
at rehab and HD was stopped.
___ notes indicate that he has had significant
swallowing issues, and has had low-grade fevers and cough. Chest
XR showed new pleural effusion but no infiltrate (unclear what
date of CXR was). He was treated with levaquin x5 days starting
___, and with bumex given the effusions.
He has had slow recovery of swallowing function at rehab, and
is still on modified diet with thickened liquids and ground
solids. He denies any recent frank aspiration events.
One day prior to presentation, he started to have mild
shortness of breath, and cough (minimally productive) with
pleuritic pain in the left posterior lower ribs and mid-right
chest. No chest tightness or pressure. His breathing has been
"hard" but denies wheezing or choking on secretions.
Denies fevers, chills, sore throat, rhinorrhea, nausea,
vomiting, abdominal pain, BRBPR, melena, constipation,
distention, urinary complaints, lower extremity edema,
orthopnea, leg pain. He notes he has had watery diarrhea for the
past week or so.
In the ED, initial vitals were: T 98.2 HR 65, BP 110/67 RR 20
SPO2 97% RA
- Exam notable for: nonreproducible chest pain, murmur c/w MV
replacement, no HSM, no ___ edema, lungs coarse at bases. No
respiratory distress.
- Labs notable for:
--WBC 12.9 (78% PMNs), Hgb 9.4, plt 417
--INR 1.3
--Na 133, K 4.1, HCO3 21, creatinine 1.0, BUN 16, glucose 100,
anion gap 19
--pro BNP 383, troponin T <0.01
--urinalysis: trace protein, few bacteria, otherwise negative
- Imaging was notable for: CXR demonstrated bibasilar
consolidations, worrisome for pneumonia, with atelectasis.
- Patient was given: cefepime 2g, vancomycin IV. He had to be
given diphenhydramine for itching, which was attributed to
vancomycin, and so the rate of vanco infusion was slowed.
Past Medical History:
Anxiety
Complete Heart Block status post PPM placement
Depression
Empty Sella Syndrome
Hyperlipidemia
Hypertension
Hyponatremia with possible SIADH
Hypothyroid
Mitral Regurgitation
Mitral Valve Prolapse
Obstructive Sleep Apnea
Social History:
___
Family History:
No premature coronary artery disease
Mother - conduction abnormality -- PPM in her ___
Physical Exam:
ADMISSION EXAM:
===============
Vital Signs: T97.9, BP 113 / 73, HR 73 RR20, SPO2 94 ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Bilateral lower to mid lung fields with rhonchi and
rales. No wheezing. Shallow breathing, without tachypnea. Deep
breaths provoke coughing and wincing in pain.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No asymmetry in diameter of calves.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE EXAM:
===============
PHYSICAL EXAM: I/O:1392/900
Weight: 205.69 lb from 94.8 kg (___)
Vitals: 97.3 PO 116/61 63 ___ RA
General: Alert and oriented, no acute distress, intermittent
cough
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP at 5 cm with bed at 30 degrees, no LAD
Lungs: bibasilar crackles
CV: Distant heart sounds; Regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No obvious lesions appreciated
Neuro: alert and oriented X3, CNII-XII grossly intact; BLE and
UE strength intact.
Pertinent Results:
ADMISSION LABS:
==============
___ 01:30PM BLOOD WBC-12.9* RBC-3.16* Hgb-9.4* Hct-28.8*
MCV-91 MCH-29.7 MCHC-32.6 RDW-14.6 RDWSD-49.0* Plt ___
___ 01:30PM BLOOD Neuts-78.4* Lymphs-9.3* Monos-7.1 Eos-3.8
Baso-0.5 Im ___ AbsNeut-10.12*# AbsLymp-1.20 AbsMono-0.91*
AbsEos-0.49 AbsBaso-0.06
___ 01:30PM BLOOD ___ PTT-30.2 ___
___ 01:30PM BLOOD Glucose-100 UreaN-16 Creat-1.0# Na-133
K-4.1 Cl-98 HCO3-21* AnGap-18
___ 06:10AM BLOOD ALT-67* AST-33 AlkPhos-93 TotBili-0.2
___ 01:30PM BLOOD proBNP-383*
___ 06:10AM BLOOD Albumin-PND Calcium-8.6 Phos-4.5 Mg-2.2
IMAGING:
=======
CXR ___ FINDINGS:
Patient is status post median sternotomy and cardiac valve
replacement. Dual lead left-sided pacemaker is seen with lead
extending 2 the expected positions of the right atrium right
ventricle. Bibasilar opacities are seen worrisome for
consolidation, possibly due to pneumonia or aspiration. Linear
right upper lobe opacity most likely represents
Atelectasis/scarring. No pleural effusion is seen. There is no
evidence of pneumothorax. Cardiac size is borderline.
The mediastinum is not widened.
IMPRESSION:
Bibasilar consolidations, worrisome for pneumonia or aspiration,
with likely some atelectasis.
VIDEO SWALLOW ___
1. Asymmetric swallowing with left-sided pharyngeal weakness.
Recommend
direct visual inspection with laryngoscopy.
2. Delayed swallow initiation with all consistencies.
3. Penetration of consecutively sipped thin liquids, improved
with head turn, chin-tuck, or single sip maneuvers.
4. No aspiration.
Please refer to the speech and swallow division note in OMR for
full details, assessment, and recommendations.
RECOMMENDATION(S): Asymmetric swallowing with left-sided
pharyngeal weakness. Recommend direct visual inspection with
laryngoscopy.
CXR ___:
IMPRESSION:
No gross change compared with ___.
Status post sternotomy, with dual lead pacemaker.
Cardiomediastinal
silhouette is unchanged.
As before, the basilar opacities raise the possibility of
infectious
infiltrates or changes related to aspiration pneumonitis.
Minimal, if any, pleural fluid.
Mild vascular plethora suggesting mild CHF, also similar to the
prior study.
No pneumothorax detected. Likely ___ artifact adjacent to the
aortic knob.
MICRO:
======
Sputum ___ 10:12 am SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and >10 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.
Urine ___ 10:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
BCx ___
NGTD
DISCHARGE LABS:
=============
___ 06:14AM BLOOD WBC-8.9 RBC-2.79* Hgb-8.3* Hct-25.7*
MCV-92 MCH-29.7 MCHC-32.3 RDW-14.6 RDWSD-49.4* Plt ___
___ 06:14AM BLOOD Glucose-85 UreaN-12 Creat-1.0 Na-135
K-4.5 Cl-102 HCO3-23 AnGap-15
___ 06:14AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
4. Escitalopram Oxalate 10 mg PO DAILY
5. Levothyroxine Sodium 175 mcg PO DAILY
6. Metoprolol Tartrate 25 mg PO TID
7. Miconazole 2% Cream 1 Appl TP BID
8. Omeprazole 20 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY
10. amLODIPine 10 mg PO DAILY
11. ClonazePAM 1 mg PO DAILY
12. TraZODone 50 mg PO QHS
13. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild
14. Bisacodyl 10 mg PR QHS:PRN constipation
15. LORazepam 0.5 mg PO Q8H:PRN anxiety
16. Furosemide 20 mg PO DAILY
17. Saccharomyces boulardii 250 mg oral BID
18. Tamsulosin 0.4 mg PO QHS
19. Benzonatate 100 mg PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
HCAP
Chronic diastolic CHF
Dysphagia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with chest pain// eval for infiltrate
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Patient is status post median sternotomy and cardiac valve replacement. Dual
lead left-sided pacemaker is seen with lead extending 2 the expected positions
of the right atrium right ventricle. Bibasilar opacities are seen worrisome
for consolidation, possibly due to pneumonia or aspiration. Linear right upper
lobe opacity most likely represents atelectasis/scarring. No pleural effusion
is seen. There is no evidence of pneumothorax. Cardiac size is borderline.
The mediastinum is not widened.
IMPRESSION:
Bibasilar consolidations, worrisome for pneumonia or aspiration, with likely
some atelectasis.
Radiology Report
EXAMINATION: Oropharyngeal swallowing video fluoroscopy
INDICATION: ___ year old man with dysphagia.
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
DOSE: Fluoro time: 03:45 min.
COMPARISON: None.
FINDINGS:
There is delayed swallow initiation with all consistencies. Swallowing was
asymmetric in the frontal view with left-sided weakness. There was
penetration of consecutively sipped thin liquids, which improved with head
turn, chin-tuck, or single sip maneuvers. A moderate amount of residue
collected within the bilateral piriform sinuses. No aspiration.
IMPRESSION:
1. Asymmetric swallowing with left-sided pharyngeal weakness. Recommend
direct visual inspection with laryngoscopy.
2. Delayed swallow initiation with all consistencies.
3. Penetration of consecutively sipped thin liquids, improved with head turn,
chin-tuck, or single sip maneuvers.
4. No aspiration.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
RECOMMENDATION(S): Asymmetric swallowing with left-sided pharyngeal weakness.
Recommend direct visual inspection with laryngoscopy.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with prior bibasilar opacities// evolution of
prior bibasilar opacities
COMPARISON: Chest x-ray from ___ at 14:08.
FINDINGS:
Dual lead left-sided pacemaker in place, with lead tips over right atrium
right ventricle. Status post sternotomy, with prosthetic valve. Heart size
is at the upper limits of normal. The cardiomediastinal silhouette is
unchanged.
Again seen is vascular plethora, suggesting mild CHF.
There are also opacities at both bases, similar to the prior study.
Corresponding patchy opacities noted in the lower lobe on lateral view.
Blunting of the costophrenic angles, without gross effusion, similar to prior.
Again seen is platelike atelectasis in the right upper zone.
No conventional pneumothorax is detected. Curvilinear lucency along the
aortic knob raises possibility of a small amount of mediastinal air, but is
similar to the appearance on the ___ and ___ radiographs
and may represent ___ artifact.
IMPRESSION:
No gross change compared with ___.
Status post sternotomy, with dual lead pacemaker. Cardiomediastinal
silhouette is unchanged.
As before, the basilar opacities raise the possibility of infectious
infiltrates or changes related to aspiration pneumonitis. Minimal, if any,
pleural fluid.
Mild vascular plethora suggesting mild CHF, also similar to the prior study.
No pneumothorax detected. Likely ___ artifact adjacent to the aortic knob.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Chest pain, Dyspnea
Diagnosed with Pneumonia, unspecified organism
temperature: 98.2
heartrate: 65.0
resprate: 20.0
o2sat: 97.0
sbp: 110.0
dbp: 67.0
level of pain: 10
level of acuity: 2.0 | Mr. ___,
You were hospitalized for chest pain and cough. We found you
had a pneumonia and treated you with antibiotics. Thankfully
you improved significantly. You then returned to rehab.
It was a pleasure taking care of you!
Your ___ team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
___
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a pleasant ___ yo woman with medical history of
HTN who was transferred from an OSH for management of a new
thalamic IPH. Per reports she was in her usual state of health
today, and developed mild confusion. So her family took her to
___. There a NCHCT showed intraparenchymal hemorrhage.
At the time she was noted to have an SBP of 200, so she was
started on nicardipine gtt.
Per daughter picked her up a 2:30pm to go to laudromat. She
noted her to be somewhat confused. Saying she was not ok but
then saying that she was. They went to the Laudromat, and then
she allowed her daughter to drive her home which is out of
character. She was off balance per the daughter "kind of
staggering". She left her at home and when returned she seemed
confused. She was following commands but felt tired. She did not
have issues with her speech just confusion. At baseline she has
cataracts and difficulty with vision so she attributed her
unsteadiness to this. She did not answer correctly to her
daughter asking who the president was. She was taken to an OSH
where her NCHCT showed an IPH.
Past Medical History:
1. DMII
2. HTN
3. HLD
Social History:
___
Family History:
Son: With AVM
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals:
T: 98.3
HR: 76
BP: 139/66
RR: 18
SaO2: 98% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
Awake, alert, oriented to person and place but not date. Able to
relate history with dauhgters assistance. Attentive, able to
name ___ backward without difficulty. Speech is fluent with full
sentences, intact repetition, and intact verbal comprehension.
Naming intact. No paraphasias. No dysarthria. Normal prosody.
Able to register 3 objects and recall ___ at 5 minutes. No
apraxia. No evidence of hemineglect. No left-right confusion.
Able to follow both midline and appendicular commands.
- Cranial Nerves - PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor - Normal bulk and decreased tone. No drift. No tremor or
asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4 ___ ___ 4 5 5 5 5 5
R 4 ___ ___ 4 5 5 5 5 5
- Sensory - No deficits to light touch, pin, or proprioception
bilaterally. No exinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating movements.
- Gait - Deferred.
==========================================================
DISCHARGE PHYSICAL EXAM:
98.3 BP 133-164/59-62 HR ___ RR ___ SAT 98% RA GLUCOSE
143-177
Neurologic Examination:
Awake, alert, oriented to person, place and time. Had trouble
remembering why she was in the hospital. Attentive, able to name
MOW backward without difficulty. Speech is fluent with full
sentences, intact repetition, and intact verbal comprehension.
Naming intact. No paraphasias. No dysarthria. Normal prosody.
Able to register 3 objects and recall ___ at 5 minutes. No
apraxia. No evidence of hemineglect. No left-right confusion.
Able to follow both midline and appendicular commands.
- Cranial Nerves - PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor - Normal bulk and decreased tone. No drift. No tremor or
asterixis.
No drift.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 4 5 5 5 5
R 5 ___ ___ 4 5 5 5 5
- Sensory - No deficits to light touch.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally.
- Gait - Walks unassisted with good stride, normal step height.
Pertinent Results:
ADMISSION LABS:
___ 01:35AM URINE COLOR-Straw APPEAR-Hazy SP ___
___ 01:35AM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-LG
___ 01:35AM URINE RBC-2 WBC-5 BACTERIA-FEW YEAST-NONE
EPI-11
___ 12:45AM GLUCOSE-164* UREA N-9 CREAT-0.6 SODIUM-140
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-26 ANION GAP-15
___ 12:45AM cTropnT-<0.01
___ 12:45AM WBC-6.0 RBC-4.44 HGB-12.8 HCT-39.0 MCV-88
MCH-28.8 MCHC-32.8 RDW-12.9 RDWSD-41.1
___ 12:45AM NEUTS-65.2 LYMPHS-18.8* MONOS-8.5 EOS-6.0
BASOS-1.0 IM ___ AbsNeut-3.91 AbsLymp-1.13* AbsMono-0.51
AbsEos-0.36 AbsBaso-0.06
___ 12:45AM PLT COUNT-242
___ 12:45AM ___ PTT-31.2 ___
IMAGING:
CT HEAD ___:
1. No significant interval change.
2. Persistent left thalamic intraparenchymal hemorrhage without
evidence of new hemorrhage.
3. Persistent, active paranasal sinus disease.
DISCHARGE LABS:
___ 03:25AM BLOOD WBC-6.3 RBC-4.32 Hgb-12.2 Hct-38.1 MCV-88
MCH-28.2 MCHC-32.0 RDW-13.2 RDWSD-42.9 Plt ___
___ 03:25AM BLOOD Glucose-120* UreaN-16 Creat-0.6 Na-144
K-3.3 Cl-107 HCO3-27 AnGap-13
___ 03:25AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.1
___ 03:25AM BLOOD %HbA1c-6.4* eAG-137*
___ 03:25AM BLOOD TSH-5.1*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 30 mg PO DAILY
2. GlipiZIDE 5 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO BID
Discharge Medications:
1. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
2. GlipiZIDE 5 mg PO DAILY
3. Metoprolol Tartrate 25 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left thalamic intraparenchymal hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ woman with hypertension ending new thalamic
intraparenchymal hemorrhage. Evaluate for interval change.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.8 s, 16.5 cm; CTDIvol = 51.4 mGy (Head) DLP =
848.0 mGy-cm.
Total DLP (Head) = 848 mGy-cm.
COMPARISON: Noncontrast head CT performed at an outside facility, ___
___, dated ___ and uploaded onto PACS.
FINDINGS:
No significant interval change from the prior CT.
Hyperdensity in the left thalamus corresponds to the known acute
intraparenchymal hemorrhage and is overall similar in size in appearance to
the prior exam (series 3, image 15). No new hemorrhage. A focal hypodensity
in the periventricular white matter are of the right frontal lobe is unchanged
from the prior exam and has density similar to CSF, likely reflecting a old
infarct (series 3, image 19). A small hypodensity in the left basal ganglia
is most likely a dilated perivascular space rather than an old lacunar
infarct, unchanged (series 3, image 13). Bilateral periventricular white
matter hypodensities are nonspecific but most likely reflect sequelae of
chronic small vessel ischemic disease, unchanged. Gray-white matter
differentiation appears preserved. Incidental bilateral calcifications of the
cavernous internal carotid artery is are moderate.
No shift of normally midline structures. The basal cisterns are patent. The
overall configuration and size of the ventricles are unchanged with background
bilateral prominence of the ventricles and sulci consistent with age-related
involutional change.
No evidence of fracture. Air-fluid level in the right and air slice
secretions in the left frontal sinuses are overall unchanged and suggests
active inflammation. There is mucosal thickening and partial opacification of
some of the bilateral ethmoidal air cells, similar the prior exam. The
remaining incompletely visualized paranasal sinus clear. The mastoid air
cells and middle ear cavities are clear. The visualized portion of the orbits
are unremarkable.
IMPRESSION:
1. No significant interval change.
2. Persistent left thalamic intraparenchymal hemorrhage without evidence of
new hemorrhage.
3. Persistent, active paranasal sinus disease.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SAH, Transfer
Diagnosed with Other nontraumatic intracerebral hemorrhage
temperature: 98.3
heartrate: 76.0
resprate: 18.0
o2sat: 98.0
sbp: 139.0
dbp: 66.0
level of pain: 0
level of acuity: 2.0 | Dear Ms. ___,
You were admitted to the hospital with a brain hemorrhage. This
was most likely cause by high blood pressure. It is very
important for you to take you blood pressure medications to
prevent future brain bleeds. The bleed caused mild weakness on
your right side, but this is improving.
We made the following changes to your medications while you were
in the hospital:
LISINOPRIL INCREASED to 40mg daily
STARTED METOPROLOL TARTRATE 25mg twice a day
Please follow-up with your PCP and neurologist.
It was a pleasure taking care of you,
Your ___ Neurologists |
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:
Laparoscopic converted to open cholecystectomy
History of Present Illness:
___ w/ PMH of CKD, DM, HTN who was recently discharged from
the ortho service s/p left total knee arthroplasty who presents
to the ED with a several hour history of RUQ pain. He states
that
he has never had similar pain in the past. The pain is constant,
is unrelated to meals and radiates to his shoulderblade. He
denies any recent fevers, chills, changes in his bowel habbits
or
shortness of breath. He does feel nauseated. No prior abdominal
surgeries. CT of the torso was concerning for a distended
gallbladder with wall edema concerning for cholecystitis. He
does
report a one year history of occasional heartburn with meals.
Past Medical History:
OSA (has CPAP, not used much), dyslipid, OA, DM, renal
cyst, CRI (baseline Cr 1.3)
Social History:
___
Family History:
NC
Physical Exam:
Vitals: 98.1 88 157/79 18 97RA
GEN: A&Ox3, NAD
HEENT: No scleral icterus
CV: RRR, no m/r/g
PULM: CTAB
ABD: Soft, nondistended, mildly tender to palpation near
incision sites, incisions c/d/i, no rebound orguarding
Ext: 1+ ___ to mid shin, no clubbing or cyanosis
Pertinent Results:
___ 10:43PM BLOOD ALT-22 AST-33 AlkPhos-82 TotBili-0.5
___ 07:30AM BLOOD ALT-237* AST-334* AlkPhos-145*
TotBili-2.4*
___ 07:25AM BLOOD ALT-199* AST-129* AlkPhos-150* Amylase-45
TotBili-4.6*
___ 07:30AM BLOOD ALT-141* AST-85* LD(LDH)-171 AlkPhos-135*
Amylase-16 TotBili-3.1*
___ 09:40AM BLOOD ALT-93* AST-44* AlkPhos-126 TotBili-2.2*
___ 07:40AM BLOOD ALT-82* AST-50* AlkPhos-162* TotBili-1.7*
___ 07:50AM BLOOD ALT-75* AST-48* AlkPhos-166* TotBili-1.5
___ 09:00AM BLOOD ALT-70* AST-42* AlkPhos-177* TotBili-1.6*
___ 08:00AM BLOOD ALT-57* AST-31 AlkPhos-158* TotBili-1.2
___ 12:58AM BLOOD CK-MB-2 cTropnT-0.01
___ 07:40AM BLOOD cTropnT-0.01
___ 12:58AM BLOOD Glucose-117* UreaN-13 Creat-0.8 Na-132*
K-4.1 Cl-98 HCO3-22 AnGap-16
___ CTA Chest w/wo Contrast; CT Abd/Pelvis:
1. No evidence of pulmonary embolism to the segmental level.
Evaluation of the subsegmental pulmonary arteries is limited by
respiratory motion
2. Distended gallbladder with gallbladder wall edema could be
consistent with cholecystitis in the correct clinical setting
3. No evidence of bowel perforation.
4. 2.5 cm hypodense lesion within the liver with enhancing
septation is
incompletely characterized. Recommend further evaluation with
nonemergent
ultrasound.
___ RUQ US:
Sludge within a distended gallbladder with gallbladder wall
edema and positive sonographic ___ sign compatible with acute
cholecystitis. No biliary dilatation.
___
Sinus tachycardia with frequent ventricular premature
contractions. Compared to the previous tracing of ___ the
findings are similar, although the ventricular premature
contractions are less frequent and the QRS voltage in the
lateral precordial leads is less prominent.
Medications on Admission:
1. Acetaminophen 1000 mg PO Q8H
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Lisinopril 5 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Simvastatin 20 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Enoxaparin Sodium 40 mg SC DAILY Duration: 28 Days
10. Senna 8.6 mg PO BID
11. Gabapentin 300 mg PO HS
12. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
13. Tamsulosin 0.4 mg PO HS
14. Aspirin 81 mg PO DAILY
15. Triamcinolone Acetonide 0.1% Cream 1 Appl TP PRN rash
16. Pseudoephedrine 30 mg PO Q6H:PRN allergy symptoms
17. phenylephrine HCl 10 mg oral Q6H:PRN allergy symptoms
18. nystatin 100,000 unit/gram topical BID:PRN rash
19. Fish Oil (Omega 3) 1200 mg PO DAILY
20. DiphenhydrAMINE 25 mg PO Q6H:PRN allergy symptom
Discharge Medications:
1. Acetaminophen 325 mg PO Q4H
RX *acetaminophen 325 mg 1 tablet(s) by mouth every 4 hours Disp
#*100 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 500 mg PO QID:PRN indigestion
4. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Gabapentin 300 mg PO HS
7. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 4
hours Disp #*50 Tablet Refills:*0
8. Lisinopril 5 mg PO DAILY
9. MetFORMIN (Glucophage) 1000 mg PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Simvastatin 20 mg PO DAILY
12. Tamsulosin 0.4 mg PO HS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Gangrenous cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with RUQ abd pain // eval for cholecystitis, duct
dilation
TECHNIQUE: Grey scale and color Doppler ultrasound images of thegallbladder
were obtained.
COMPARISON: CT abdomen and pelvis dated ___
FINDINGS:
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 5 mm.
GALLBLADDER: There is gallbladder wall edema with sludge within the distended
gallbladder and a positive sonographic ___ sign.
The patient was unable to tolerate the remainder of the exam due to pain.
IMPRESSION:
Sludge within a distended gallbladder with gallbladder wall edema and positive
sonographic ___ sign compatible with acute cholecystitis. No biliary
dilatation.
Radiology Report
STUDY: AP chest ___.
CLINICAL HISTORY: ___ man with frequent PVCs, now with new-onset
chest pain, post-op day 2.
FINDINGS: Comparison is made to prior study from ___.
There are low lung volumes. There is a right-sided pleural effusion. There
has been improvement of the pulmonary edema since the prior study. There is
atelectasis at the lung bases. There are no pneumothoraces.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: RUQ abdominal pain
Diagnosed with ACUTE CHOLECYSTITIS, ATRIAL FIBRILLATION, DIABETES UNCOMPL ADULT, HYPERTENSION NOS
temperature: 98.2
heartrate: 100.0
resprate: 20.0
o2sat: 100.0
sbp: 181.0
dbp: 101.0
level of pain: 10
level of acuity: 3.0 | Mr. ___
It was a pleasure taking care of you here at ___
___. You were admitted to our hospital
after undergoing removal of your gallbladder. You have recovered
nicely from surgery and are now ready to be discharged to home.
Please follow the recommendations below to ensure a speedy and
uneventful recovery.
ACTIVITY:
-Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
-You may climb stairs.
-You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
-Don't lift more than 10 lbs for 6 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.)
-You may start some light exercise when you feel comfortable.
-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.
-Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
-You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
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:
-Your incision may be slightly red around the edges. This is
normal.
-You may gently wash away dried material around your incision.
-It is normal to feel a firm ridge along the incision. This will
go away.
-Avoid direct sun exposure to the incision area.
-Do not use any ointments on the incision unless you were told
otherwise.
-You may see a small amount of clear or light red fluid staining
your dressing r clothes. If the staining is severe, please call
your surgeon.
-You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
-Over the next ___ months, your incision will fade and become
less prominent.
YOUR BOWELS:
-Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
-If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
-After some operations, diarrhea can occur. If you get diarrhea,
don't take anti-diarrhea medicines. Drink plenty of fluitds and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your surgeon.
PAIN MANAGEMENT:
-It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
-Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
-You will receive a prescription from your surgeon for pain
medicine to take by mouth. It is important to take this medicine
as directied.
Do not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
-Your pain medicine will work better if you take it before your
pain gets too severe.
-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.
-If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
-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 folloiwng, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
-Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
-If you have any questions about what medicine to take or not to
take, please call your surgeon. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
Defibrillation
Cardiac catheterization
History of Present Illness:
___ w/ hx of lumbar stenosis s/p lumbar laminectomy on ___,
hypothyroidism, depression p/w headache and syncope.
Of note, patient underwent bilateral L4 hemilaminectomy and
L5-S1 laminectomy on ___ for spinal stenosis c/b by deep
MSSA intraspinal abscess requiring debridement, bilateral L2
hemilaminectomy, L3 laminectomy, revision L4 bilateral
hemilaminectomy and repair of dural leak on ___. Patient was
then to continue IV nafcillin until ___.
Since then patient has had intermittent headaches and pain at
lumbar spine, with occasional tingling and pain of his bilateral
thighs. Today, the patient had a worse than typical headache
which was bifrontal and radiated to his bilateral temples, as
well as low back pain which was worse than typical. He also had
a brief syncopal episode at work where he fell onto carpet
floor. He denies any new numbess, tingling or focal weakness. He
denies any recent fevers or chills. He has been getting his IV
Nafcillin as prescribed. Patient denies and bowel or bladder
incontinence or changes in habits.
In the ED, initial vitals were ___ 160/90 20. He had another
2 syncopal episodes, these episodes lasted approximately 5
seconds. During the first episode he was noted to have small
jerking motions of his upper extremities which only occured when
he was momentarily unresponsive. After regaining consciousness
he was not confused and was completely alert and oriented. He
had no tongue biting or bowel or bladder incontinence. During
his second syncopal episode he had been placed on telemetry and
was noted to have a 5 second run of torsades. Spine saw him and
recommended inpatient MRI.
ECG was sinus with 1st degree AV block, LAD and LBBB. Labs
notable for potassium 2.7 and magnesium of 2.6, CRP 6.8,
negative troponin and lactate. Imaging notable for negative Head
CT. Patient received 4mg Zofran, 1mg dilaudid, 40mEq IV
potassium, 40mEq PO potatssium and 2g magnesium.
On the floor, the pt complains of headache and nausea which are
improved from previously. he continues to have pain in his lower
back which did not start until the spinal surgeons were
palpating his back in the ED. Nothing seems to improve this new
pain. For the past six weeks he has also had diarrhea from the
nafcillin, which has improved over the last few days using
probiotics.
Past Medical History:
Hypothyroidism - pt reports he is on thyroid replacement
empirically for thyroid nodules but has never had low thyroid
hormone
Depression
Spinal stenosis s/p laminectomy ___ c/b post-op wound infection
and requiring repair of dural leak and debridement on IV
nafcillin x 6 wks
Onychomycosis
Social History:
___
Family History:
No history of heart disease or sudden death in the family.
Variety of cancers.
Physical Exam:
Admission physical exam:
VS- T=99 BP=147/98 HR=96 RR=18 O2 sat= 99% RA
GENERAL- Thin apearing Caucasian male in NAD. Oriented x3. Mood,
affect appropriate.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK- Supple with no JVD. No CLAD.
CARDIAC- PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, split S2. No m/r/g. No thrills, lifts. No
S3 or S4.
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN- Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
BACK- midline lumbar spinal incision, well healed. TTP diffusely
near incision. No swelling or erythema.
EXTREMITIES- No c/c/e.
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES-
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
NEURO: CNII-XII grossly intact. ___ strength, normal sensation.
ROM limited by pain in back.
Discharge physical exam:
VS - TC 98.6 TM 98.7 BP 127/93 HR 82 RR 16 SAO2 97RA
I/O - 680/650+BR
Wt - 67kg ___ yesterday)
GENERAL- Thin apearing Caucasian male in NAD. Oriented x3. Mood,
affect appropriate.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK- Supple with no JVD. No CLAD. Pt has difficulty bending
neck to touch chin.
CARDIAC- PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, split S2. No m/r/g. No thrills, lifts. No
S3 or S4.
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, bibasilar soft
crackles, wheezes or rhonchi.
ABDOMEN- Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
BACK- midline lumbar spinal incision, well healed. TTP diffusely
near incision. No swelling or erythema.
EXTREMITIES- No c/c/e.
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES-
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
NEURO: CNII-XII grossly intact. ___ strength, normal sensation.
ROM limited by pain in back.
Pertinent Results:
Admission labs:
___ 11:30AM BLOOD WBC-9.8 RBC-3.58*# Hgb-12.8*# Hct-37.8*#
MCV-106* MCH-35.8* MCHC-33.9 RDW-14.7 Plt ___
___ 11:30AM BLOOD Neuts-72.7* ___ Monos-5.1 Eos-3.3
Baso-0.5
___ 11:30AM BLOOD ___ PTT-27.6 ___
___ 11:30AM BLOOD Glucose-96 UreaN-9 Creat-0.7 Na-142 K-4.3
Cl-99 HCO3-26 AnGap-21*
___ 03:10AM BLOOD proBNP-___*
___ 12:55PM BLOOD cTropnT-<0.01
___ 11:30AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.0
___ 05:00AM BLOOD calTIBC-231* Ferritn-72 TRF-178*
___ 03:45PM BLOOD Osmolal-264*
___ 12:07AM BLOOD TSH-5.2*
___ 05:00AM BLOOD Free T4-1.0
___ 04:44AM BLOOD Cortsol-19.2
___ 11:30AM BLOOD CRP-6.8*
___ 05:00AM BLOOD PEP-NO SPECIFI
___ 05:00AM BLOOD HIV Ab-NEGATIVE
___ 01:07PM BLOOD Lactate-2.0
Discharge labs:
___ 03:10AM BLOOD WBC-9.7 RBC-3.54* Hgb-12.6* Hct-36.6*
MCV-103* MCH-35.6* MCHC-34.5 RDW-13.9 Plt ___
___ 09:25AM BLOOD Neuts-87.3* Lymphs-8.1* Monos-3.9 Eos-0.3
Baso-0.5
___ 04:44AM BLOOD ___
___ 03:10AM BLOOD Glucose-106* UreaN-16 Creat-0.8 Na-130*
K-4.3 Cl-94* HCO3-27 AnGap-13
___ 03:10AM BLOOD Calcium-9.1 Phos-4.7* Mg-2.1
URINE CHEMISTRYHoursUreaNCreatNaKClTotProt
___ 20:52 ___
Source: ___
___ 16:35 RANDOM 12
Source: ___
OTHER URINE CHEMISTRYU-PEPOsmolal
___ 20:52 611
Source: ___
___ 16:35 NO PROTEIN1
Source: ___
Pertinent micro/path:
Blood cultures neg x2
Pertinent imaging:
Head CT: No acute intracranial process
EKG: sinus at 80, QTc 467, LAD with LBBB, does not meet
Sgarbossa's criteria
TTE ___:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is global LV hypokinesis with relative
preservation of systolic function of tha basal to mid lateral
wall. The septum and inferior walls appear akinetic. Overall
left ventricular systolic function is severely depressed (LVEF=
25 %). There is LV dysychrony (LBBB). No masses or thrombi are
seen in the left ventricle. There is no ventricular septal
defect. Right ventricular chamber size is normal. with
borderline normal free wall function. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is a
very small pericardial effusion. There are no echocardiographic
signs of tamponade.
IMPRESSION: Cardiomyopathy.
___ MR ___ SPINE:
Since the previous MRI, there has been superior extension of the
laminectomy with a posterior epidural fluid collection causing
moderate-to-severe canal stenosis, worst at L4-L5 where there is
an anterior disc protrusion which contributes to the canal
narrowing. The differential would include a postoperative
seroma/resolving hematoma, although superimposed infection
cannot be excluded.
Preliminary Catheterization Report
Patient Information
Patient Name ___, ___ ___ ___
Study Date ___ Number ___
Date of Birth ___ ___ Years
GenderMale Race
Height170 cm (5'7'')Weight67 kg (148 lbs)
BSA1.78 M2
Procedures: Catheter placement, Coronary Angiography
Indications: Dilated Cardiomyopathy
Staff
Diagnostic ___, MD
___, RN
Technologist___, RTR
___, MD
___, RN
___, MD
___, CVT
Technical
Anesthesia: Local
Specimens: None
Catheter placement via 5 ___ sheath right femoral artery and
right femoral vein
Coronary angiography using 5 ___ JL4 and JR4
Blood Oximetry Information
TimeSiteHgb (gm/dL)Sat (%)PO2
(mmHg)Content
(ml per dl)
6:51 PMPA ___
7:09 PMART 12.3099.6016.66
Cardiac Output Results
PhaseFick
C.O.(l/min)Fick
C.I. (l/min /m2)TD
CO (l/min)TD
CI (l/min/m2)
3.632.04
Hemodynamic Measurements (mmHg)
SiteSysDiasEndMeanA WaveV WaveHR
___ ___ ___
RV ___
RA ___
LV ___ ___
Contrast Summary
ContrastTotal (ml)
Omnipaque (300 mg/ml)50
Radiation Dosage
Effective Equivalent Dose Index (mGy)___
Radiology Summary
Total Runs
Total Fluoro Time (minutes)7.3
Findings
ESTIMATED blood loss: < 25 cc
Hemodynamics (see above): The left heart pressures were
substantially elevated (PCWP 31 mmHg).
Coronary angiography: right dominant
LMCA: Normal
LAD: Normal. The LAD had minimal lumen irregularities.
The ___ diagonal branch had minimal lumen irregularities
LCX: Normal/ There was a large ___ obtuse marginal branch
and a large ___ posterolateral branch.
RCA: Normal. It gave rise to a PDA and large posterolateral
Assessment & Recommendations
1.Dilated cardiomyopathy
2.Elevated left heart filling pressures (PCWP 31 mmHg)
3.Normal coronary arteries
4.Diuresis
Medications on Admission:
The Preadmissions Medication list may be inaccurate and require
further investigation.
1. Nafcillin 2 g IV Q4H Duration: 6 Weeks
last day ___. terbinafine *NF* 250 mg Oral daily
3. Levothyroxine Sodium 150 mcg PO DAILY
4. Citalopram 30 mg PO DAILY
5. HYDROmorphone (Dilaudid) ___ mg PO Frequency is Unknown
6. Acetaminophen 650 mg PO Q6H:PRN pain, fever
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain, fever
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Ferrous Gluconate 325 mg PO DAILY
RX *ferrous gluconate 325 mg (37.5 mg) 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
4. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Lisinopril 20 mg PO DAILY
Please hold SBP < 100
RX *lisinopril 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Metoprolol Succinate XL 50 mg PO DAILY
hold for SBP <95 or HR <55
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
7. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN breakthrough
pain
RX *oxycodone 5 mg 2 tablet(s) by mouth every 8 hours Disp #*20
Tablet Refills:*0
8. Senna 1 TAB PO BID:PRN constipation
9. Outpatient Lab Work
425.5 Chem 10. Please contact Dr. ___ at ___ with the
results.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Torsades
Hypokalemia
Hyponatremia
Cardiomyopathy
SECONDARY
Lumbar stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Sudden-onset headache and syncope. Of note, patient had recent
spinal surgery in ___ complicated by postop wound infection and CSF leak.
Evaluate for acute intracranial process.
COMPARISON: None.
TECHNIQUE: Sequential axial images were acquired through the head without
administration of intravenous contrast material. Multiplanar reformats were
performed.
FINDINGS: There is no evidence of intracranial hemorrhage, edema, shift of
normally midline structures, hydrocephalus, or acute large vascular
territorial infarction. The imaged portions of the orbits are unremarkable.
There is minimal mucosal thickening within a right anterior ethmoidal air
cell. The remainder of the visualized portions of the paranasal sinuses and
mastoid air cells are well aerated. The imaged osseous structures are
unremarkable.
IMPRESSION: No acute intracranial process.
Radiology Report
HISTORY: PICC placement.
FINDINGS: The right PICC line extends to the upper portion of the SVC. There
is continued enlargement of the cardiac silhouette with poor definition of
lower lung vessels consistent with elevated pulmonary venous pressure. No
evidence of acute focal pneumonia. Clips from previous thyroid surgery are
again seen in the lower cervical region.
Radiology Report
TECHNIQUE: MRI of the complete spine without and with gad.
HISTORY: Previous surgery, now still with headaches and back pain. Assess
for resolution of abscess.
___.
FINDINGS:The patient is status post L2 through L5 laminectomy. The
laminectomy appears to extend more superiorly than on the previous MRI. There
is posterior epidural fluid collection extending from L2 through L5 causing
moderate spinal canal narrowing. There is severe spinal canal narrowing at
L4-L5 due to the posterior fluid collection as well as a central disc
protrusion. The collection contains some areas of low signal within it and
could potentially represent a resolving hematoma or a seroma, although
superimposed infection cannot be excluded. Diffuse disc bulge with central
disc protrusion at L2-L3 persist.
No definite cord signal abnormality is seen.
Degenerative endplate changes in the lumbar spine are stable.
Evaluation of the cervical spine demonstrates multilevel disc osteophyte
complexes causing mild-to-moderate effacement of the ventral thecal sac at
multiple levels as well as foraminal narrowing in the mid cervical spine.
There are apparent hepatic cysts.
IMPRESSION:
Since the previous MRI, there has been superior extension of the laminectomy
with a posterior epidural fluid collection causing moderate-to-severe canal
stenosis, worst at L4-L5 where there is an anterior disc protrusion which
contributes to the canal narrowing. The differential would include a
postoperative seroma/resolving hematoma, although superimposed infection
cannot be excluded.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: H/A
Diagnosed with SYNCOPE AND COLLAPSE, PAROX VENTRIC TACHYCARD
temperature: 98.0
heartrate: 80.0
resprate: 20.0
o2sat: nan
sbp: 160.0
dbp: 90.0
level of pain: 3
level of acuity: 2.0 | Dear Mr. ___,
You were admitted to ___ after you lost consciousness. You
were found to have an unusual heart rhythm that caused this
problem likely due to low potassium. An echocardiogram of your
heart showed some weakness of the heart, potentially related to
your history of drinking alcohol. A cardiac catheterization was
normal suggesting you do not have coronary artery disease. You
will be seen in the heart failure clinic for continued
management of your disease.
You also underwent an MRI of your back which showed a collection
of fluid at that site of your recent surgery that will be
addressed at your next clinic appointment with your surgeon.
The following medications were changed during this admission:
STOP nafcillin as your course is complete
STOP terbinafine as this can predispose you to unusual heart
rhythms
STOP citalopram as this can predispose you to unusual heart
rhythms
STOP flexeril as this can predispose you to unusual heart
rhythms
START lasix 20mg daily
START iron for your low iron levels
START oxycodone as needed for pain
START lisinopril 20mg for your heart and blood pressure
START metoprolol succinate 50mg for your heart and blood
pressure
Please have your potassium and sodium checked on ___ and call
Dr. ___ office at ___ with the results. If your
potassium is low at that time, you might need to start potassium
supplementation.
Weigh yourself daily and if you gain 3lbs or more in one day,
please call the heart failure clinic at ___. It is
important to eat less than 2g of sodium a day and keep your
fluid intake to 1.5L per day to help with your low sodium
levels. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___- left heart catheterization
History of Present Illness:
Mr. ___ is a ___ year old man with HTN who presents with one
month of chest burning.
The patient shares that he first noticed the chest burning the
___. His work involves carrying heavy
objects, and he first noticed the sensation with work. The first
time he ever got it it lasted somewhere from ___ minutes. The
feeling is a burning sensation in the ___ his chest,
radiates to his left neck, has occasionally radiated down both
arms, no paresthesias, no nausea, no diaphoresis, no shortness
of breath. Since then, he says he has also gotten the burning in
the morning when he wakes up. On days he works he has the pain
about 3 times per day, and on days he does not work about time
per day. He is clear that the pain does not only occur with
exertion and will happen with rest. And since the first episode,
the pain usually lasts about 5 minutes (sometimes shorter). He
thought the pain was heartburn, but says when he has heartburn
his symptoms usually last longer. He is unsure if anything makes
the pain worse or better; he has taken tums for the pain, but
says he is unsure if it works because the pain is short lasting
either way. Because the pain was not improving, he therefore
decided to present to the ED.
In the ED initial vitals were 97.4 78 134/86 18 100 RA. Labs
were notable for Troponin <0.01, normal CBC and chem panel. EKG
showed TWI aVL, biphasic TWs V2-V4, ST changes V2-V4. CXR with
no acute cardiopulmonary abnormality. He was started on a
heparin gtt and given aspirin 325 mg.
Upon arrival to the floor the patient shares the last time he
had chest pain was the morning of presentation. He has only had
one episode of chest pain in the past 24H.
Past Medical History:
HTN
Social History:
___
Family History:
FAMILY HISTORY:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death that he knows of.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T98.3 BP114/84 HR62 RR18 O2 98 RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: No JVD.
CARDIAC: RR, normal S1, S2. No murmurs/rubs/gallops. No
thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
LABS: reviewed, see below
MICRO: none
DISCHARGE PHSYCIAL EXAM:
VS: 98 116/73 59 16 98% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa
NECK: No JVD.
CARDIAC: RR, normal S1, S2. No murmurs/rubs/gallops. No
thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No rash
LABS: reviewed, see below
MICRO: none
Pertinent Results:
ADMISSION LABS:
___ 06:45PM BLOOD WBC-6.7# RBC-4.85 Hgb-14.2 Hct-44.0
MCV-91 MCH-29.3 MCHC-32.3 RDW-13.2 RDWSD-43.1 Plt ___
___ 06:45PM BLOOD Neuts-65.0 ___ Monos-9.1 Eos-0.7*
Baso-0.3 Im ___ AbsNeut-4.34 AbsLymp-1.64 AbsMono-0.61
AbsEos-0.05 AbsBaso-0.02
___ 06:45PM BLOOD ___ PTT-31.1 ___
___ 06:45PM BLOOD Plt ___
___ 06:45PM BLOOD Glucose-124* UreaN-8 Creat-0.8 Na-139
K-4.5 Cl-101 HCO3-28 AnGap-15
___ 06:45PM BLOOD cTropnT-<0.01
___ 06:49PM BLOOD D-Dimer-378
INTERVAL LABS:
___ 03:10AM BLOOD %HbA1c-5.4 eAG-108
___ 03:10AM BLOOD Triglyc-91 HDL-56 CHOL/HD-3.6 LDLcalc-125
___ 03:10AM BLOOD CK-MB-2 cTropnT-<0.01
___ 09:37AM BLOOD cTropnT-<0.01
___ 12:57AM BLOOD cTropnT-<0.01
DISCHARGE LABS:
___ 06:15AM BLOOD WBC-4.0 RBC-4.42* Hgb-13.2* Hct-39.6*
MCV-90 MCH-29.9 MCHC-33.3 RDW-13.3 RDWSD-43.6 Plt ___
___ 06:15AM BLOOD Plt ___
___ 06:15AM BLOOD Glucose-98 UreaN-16 Creat-0.8 Na-138
K-4.0 Cl-101 HCO3-28 AnGap-13
___ 06:15AM BLOOD Triglyc-100 HDL-46 CHOL/HD-4.0
LDLcalc-116
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
4. TiCAGRELOR 90 mg PO BID
IT IS VERY IMPORTANT TO TAKE THIS MEDICINE EVERY DAY
RX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
5. Lisinopril 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
- Acute coronary syndrome with 80% occlusion of left anterior
descending coronary artery
SECONDARY DIAGNOSIS
- hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with chest pain
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. Lungs are clear. No pleural effusion or
pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Chest pain, Abnormal EKG
Diagnosed with Other chest pain
temperature: 97.4
heartrate: 78.0
resprate: 18.0
o2sat: 100.0
sbp: 134.0
dbp: 86.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
It was a pleasure taking care of you. You were admitted to ___
for chest pain. You had an EKG that was concerning for a heart
attack. Therefore, you had a catheterization of your heart and a
stent was placed to open up your heart vessel. You were started
on medicines called aspirin and ticagrelor -- it is very
important to take these every day to prevent your stent from
clotting off.
We wish you all the best in the future.
Sincerely,
Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
lisinopril / Cozaar / amiodarone
Attending: ___.
Chief Complaint:
Left lower extremity cellulitis.
Claudication
Major Surgical or Invasive Procedure:
Left Lower Extremity Angiogram
History of Present Illness:
Mr. ___ is an ___ with multiple medical comorbidities
including ischemic cardiomyopathy and PVD s/p fem-fem bypass at
an outside institution in ___. He presented to ___
___ three weeks prior to admission to ___ with worsening
left lower extremity cellulitis and mental status changes. On
admission he was also noted to have a pneumonia and was in acute
renal failure. He was resuscitated and started on antibiotics.
When he failed to improve on rocephin he was transitioned to
clindamycin with improvement in the cellulitis. He was also
started on zosyn for nosocomial pneumonia and ultimately
discharged to rehab after ten days in the hospital on a seven
day course of clindamycin, augmentin and flagyl. While at the
rehab facility he was doing well until a few days
ago when he again noticed increased redness and pain in his left
lower extremity. He was evaluated by his vascular surgeon, Dr.
___ from ___ in ___, who recommended
he come to the ___ ED for further evaulation and treatment. In
the ___ ED he reports ___ pain in his left calf and foot. He
also has claudication in his feet at baseline after walking a
few blocks but over the previous few weeks had been unable to
walk due to the pain associated with the infection and
non-healing ulcers. When asked about venous insufficiency he
reported significant swelling in his ankles at the end of the
day which resolved with leg elevation. He denies
fevers, chills or signs of systemic illness.
Past Medical History:
ischemic cardiomyopathy, MI, arrhythmia, CHF, TIA, hypertension,
gout, PVD, hyperlipidemia, pneumonia, hypertension, BPH
PSH:
operative report unavailable but per verbal report
femoral-femoral bypass with Dr. ___ Family ___, left CEA
___ Dr. ___, CABG x ___, ICD ___, bilateral hernia repair
___
Social History:
___
Family History:
Cardiac Disease
Physical Exam:
Vital Signs: 98.4 76 100/38 12 96% RA
General: awake, alert, NAD
HEENT: NCAT, EOMI, anicteric
Heart: RRR, NMRG
Lungs: CTAB, normal excursion, no respiratory distress
Back: no vertebral tenderness, no CVAT
Abdomen: soft, NT, ND, no mass, no hernia
Extremities: non-healing ulcers over the LLE with 1+ edema and
evidence of venous stasis changes. Resolved erythema. Loss
of sensation at the toes.
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RLE Femoral: P. Popliteal: P. AT D. ___: D.
LLE Femoral: P. Popliteal: P. DP: mono. ___: D. Graft: D
Pertinent Results:
___ 06:55AM GLUCOSE-95 UREA N-13 CREAT-0.7 SODIUM-139
POTASSIUM-3.5 CHLORIDE-106 TOTAL CO2-27 ANION GAP-10
___ 06:55AM CALCIUM-8.2* PHOSPHATE-2.8 MAGNESIUM-2.0
___ 06:55AM WBC-5.1 RBC-2.92* HGB-10.3* HCT-31.0*
MCV-106* MCH-35.3* MCHC-33.3 RDW-14.8
___ 06:55AM PLT COUNT-159
___ 10:30PM URINE COLOR-Amber APPEAR-Cloudy SP ___
___ 06:55AM ___ PTT-36.8* ___
___ 10:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
___ 10:30PM URINE RBC-107* WBC-71* BACTERIA-FEW YEAST-NONE
EPI-0
___ 10:30PM URINE HYALINE-142*
___ 10:30PM URINE CA OXAL-MANY
___ 09:28PM LACTATE-0.9
___ 09:16PM GLUCOSE-105* UREA N-19 CREAT-0.7 SODIUM-138
POTASSIUM-3.4 CHLORIDE-106 TOTAL CO2-29 ANION GAP-6*
___ 09:16PM estGFR-Using this
___ 09:16PM WBC-6.6 RBC-2.97* HGB-10.8* HCT-31.4*
MCV-106* MCH-36.4* MCHC-34.4 RDW-14.9
___ 09:16PM NEUTS-63.4 ___ MONOS-5.2 EOS-2.0
BASOS-0.3
___ 09:16PM PLT COUNT-164
Medications on Admission:
allopurinol ___ daily, norvasc 2.5 daily, ASA 325 daily, coreg
12.5 twice daily, colchicine 0.6 daily, lasix 60 daily, KCl
daily, zantac 150 twice daily, zocor 10 nightly, flomax 0.4
daily
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8HRS:PRN Pain
2. Amlodipine 10 mg PO DAILY
hold for SBP<120
3. Aspirin EC 325 mg PO DAILY
4. Carvedilol 12.5 mg PO BID
5. Docusate Sodium 100 mg PO BID
Patient may refuse. Hold if patient has loose stools.
6. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
7. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
8. Ranitidine 150 mg PO BID
9. Simvastatin 10 mg PO QHS
10. Tamsulosin 0.4 mg PO HS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Peripheral Arterial Disease
Left Leg Cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
STUDY: Lower extremity arterial noninvasives at rest.
REASON: Non-healing left lower extremity ulcers. History of fem-fem bypass.
FINDINGS: Doppler waveform analysis reveals monophasic waveforms throughout
bilateral lower extremities. ABIs are 0.51 on the right and 0.57 on the left.
Pulse volume recordings show mild dampening in the left thigh and moderate
dampening in the right thigh. There is further dampening at the calf level on
the right, but an absence of calf augmentation on the left.
IMPRESSION: Bilateral aortoiliac and SFA disease.
Radiology Report
INDICATION: ___ man with right leg shortening.
COMPARISONS: None.
TECHNIQUE: Bilateral hips, three views.
FINDINGS: There is no evidence of fracture or dislocation. There are
significant degenerative changes in the bilateral hips. There are vascular
calcifications. There are degenerative changes at the SI joints bilaterally
and the pubic symphysis. Degenerative changes are seen in the lumbar spine.
IMPRESSION:
1. No acute fracture or dislocation.
2. Degenerative changes in the bilateral hips.
3. Would recommend 3 FOOT Radiographs to assess leg/length stability if
clinically indicated.
Radiology Report
CLINICAL HISTORY: ___ man status post fem-fem bypass, cellulitis of
the left lower extremity.
COMPARISON: None.
TECHNIQUE: CT of the lower extremities was performed in arterial phase along
with a runoff.
FINDINGS:
CT OF THE PELVIS: Imaged soft tissues in the pelvis to include the lower pole
of the right kidney which is unremarkable and loops of small and large bowel
with fecal loading in the large bowel, an otherwise unremarkable exam. A
Foley catheter is seen within the bladder which is unremarkable. No pelvic or
inguinal lymphadenopathy is noted.
CTA: The right common iliac artery is occluded with reconstitution of flow at
the bifurcation of the external and internal common iliac (3a:31). The left
common iliac as well as external and internal iliacs are patent. A fem-fem
bypass graft is patent. On the left, there is a fem-pop bypass with patent
graft. In the popliteal fossa, there is a short segment of the popliteal
artery which appears occluded followed by two-vessel runoff with partial
occlusion of the anterior tibial artery. On the right, there is occlusion of
the superficial femoral artery with reconstitution at the popliteal and again
two-vessel runoff with occlusion of the anterior tibial artery. Extensive
arthrosclerotic disease is seen throughout the arterial vasculature of both
legs.
There is soft tissue edema with no drainable fluid collections in the left mid
calf (3a:210).
BONES: The bones are diffusely demineralized; however, no suspicious lytic or
sclerotic lesions are seen.
IMPRESSION:
1. Extensive vascular disease with two-vessel runoff in each extremity.
2. Patent fem-fem bypass as well as patent left-sided fem-pop bypass.
3. Occlusion of the right common iliac with reconstitution of flow at the
bifurcation of the internal-external iliac.
4. Occlusion of the right superficial femoral artery with reconstitution at
the popliteal.
5. Left lower leg soft tissue edema without any drainable fluid collections.
Radiology Report
HISTORY: Cardiac disease with symptoms of pneumonia.
FINDINGS: In comparison with the study of ___, there is little change.
Enlargement of the cardiac silhouette in a patient with CABG and dual-channel
pacemaker device in place. Opacification in the retrocardiac region is
consistent with some volume loss in the left lower lobe. No appreciable
pulmonary vascular congestion.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LLE CELLULITIS
Diagnosed with CELLULITIS OF LEG, HYPERTENSION NOS, AICD STATUS
temperature: 97.2
heartrate: 81.0
resprate: 14.0
o2sat: 99.0
sbp: 111.0
dbp: 94.0
level of pain: 13
level of acuity: 3.0 | You were admitted to the hospital for the care of your
cellulitis and the treatment of your lower extremity arterial
disease. You got an angiogram of your legs, it was not possible
to place a stent.
After the Test
You will be taken to another bed. You will rest for about 4
hours.
Staff will check you often.
Keep your leg straight to prevent bleeding.
Tell your nurse right away if the site swells or bleeds, or if
you feel pain,
numbness, or tingling in your leg or arm.
You can eat and drink.
It is not safe for you to drive or leave alone. An adult
family member or
friend will need to take you home.
Your Care At Home
Today
Rest at home.
Limit stair climbing.
Drink 8 cups or 2 liters of liquids (non-alcoholic) to flush
the dye out of
your kidneys.
Eat your normal diet.
Remove pressure bandage at bedtime and put on a clean
band-aid.
Keep the site dry. Do not shower or bathe.
Look at the site for bruising or a lump.
Other Care
Do not take a tub bath for 1 week after the test. You can
take a shower.
Do not scrub the site.
Do not take the medicine Glucophage (metformin) for 2 days
after the
test.
Do not drive for ___ days.
Do not exercise, run, or lift objects over 10 pounds or 4.5
kilograms for 3
days after the test.
Look at the site for bruising or a lump. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Flagyl
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
colonoscopy with biopsies on ___
History of Present Illness:
Ms. ___ is a ___ female with past medical history
of uveitis who presents with subacute worsening abdominal pain,
multi-year history of intermittent hematochezia who presents
with
worsening abdominal pain, nausea.
HPI: The patient reported that around three weeks ago she woke
up
with abdominal pain and vomiting that later remitted. Then,
___, she woke up with another episode of abdominal pain, with
associated nausea and vomiting. The pain was present throughout
her abdomen but was worse on the right side. The pain was sharp
and cramping and began in her upper abdomen and then moved to
her
lower abdomen. It persisted throughout the day, and, at its
worst
was ___. She also felt light-headed at the time. The pain
continued, and the patient presented to an OSH ED ___, where
she had CT scan with reported terminal ileitis. She was referred
for urgent outpatient GI work up.
On follow up with GI the next day there was concern for Crohn's
disease given history of uveitis and subacute nature of
abdominal
pain and ___ year history of hematochezia. Scheduled for MR
enterography in early ___ and outpatient colonoscopy for
further workup. She was prescribed ciprofloxacin and Flagyl.
Patient reports initial mild improvement with antibiotics. She
began having burning sensation of soles bilaterally and
discussed
with GI doc and flagyl was discontinued ___ AM last dose.
Pain
subsequently worsened evening of ___, the abdominal pain
worsened again, causing the patient to present. She reported
recent-onset bloating but denied any vomiting, diarrhea,
constipation, hematochezia, or fever. The patient currently
rates
the pain at ___ and reports that it is worse when sitting up.
She denies pain with driving/bumps on the road. She states she
has improvement in pain when laying flat but that episodes of
pain can wake her from sleep.
The patient reports having a "sensitive stomach" for many years.
She states for past ___ years she has had intermittent bloody
bowel
movements. These have red blood mixed within the stool rather.
She denies red streaking on the surface. Per the patient, she
recently tried reducing her gluten and dairy intake
(___), with no relief. Patient states that in the ___
she was recommended to have celiac testing done but that she had
not gotten labs drawn.
In the ED:
- Her initial vitals were notable for temperature 97.4 heart
rate 67 blood pressure 138/67 respiratory rate 18 satting 98% on
room air.
- Her exam in the ED was notable for:
"diffuse tenderness to mild palpation with absence of peritoneal
signs or rebound or guarding. Her right lower quadrant was
notably more tender with negative Rovsing's, obturator, psoas
signs. No CVA tenderness."
- Labs in the ED were notable for:
Normal CBC with white blood cell count of 6.0, normal LFTs,
normal BMP, CRP of 7.4. UA was obtained which demonstrated small
leuk esterase, small blood, negative nitrites, moderate
bacteria,
11 white blood cells.
- Imaging notable for:
___ KUB with no evidence of bowel obstruction or
intraperitoneal free air.
- Patient was given Toradol and Zofran 1X each in the ED.
- GI was consulted in ED who recommended NPO for colonoscopy,
stool studies, continuing antibiotics
On arrival to the floor, the patient reported no improvement to
toradol. She provides history as written above.
In regards to reaction to flagyl she states it felt like a
warmth
on the bottom of her feet bilaterally. She denied rash. She last
experienced it yesterday afternoon. She last took flagyl
yesterday AM.
REVIEW OF SYSTEMS:
General: Chills/sweats, although only while in severe pain.
GI: Patient denies hematemesis. Reported pain while straining to
have a bowel movement last week. Reported less frequent bowel
movements since beginning abx. Reported recent onset of
bloating.
GU: Denies any dysuria, hematuria, or mucous/discharge in urine.
GYN: Denies any vaginal discharge or bleeding.
Past Medical History:
Terminal ileitis diagnosed 1 week prior to admission
Uveitis: Patient reports diagnosed as child, affected bilateral
eyes, had followed mass eye and ear for many years, s/p
treatment
with methotrexate
Migraine headaches
Social History:
___
Family History:
Sister: IBS
Physical ___:
ADMISSION PHYSICAL EXAM:
VS: ___ 1700 Temp: 98.4 PO BP: 127/81 R Sitting HR: 71 RR:
18 O2 sat: 98% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score:
___
GENERAL: Pleasant, lying in bed comfortably
HEENT: PERRL, EOMI. Oropharynx clear, with moist mucous
membranes.
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: No increased work of breathing. Lungs clear to
auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Normoactive bowel sounds. Soft abdomen. Tympanic on
percussion. Diffusely tender throughout with no rebound
tenderness. No guarding Varying locations of most tender areas,
initially right sided and then left sided
EXT: Warm, well perfused, no lower extremity edema
PULSES: 2+ radial pulses, 2+ ___ pulses
NEURO: Alert, oriented, face symmetric at rest and with
activation, full sensation throughout, motor and sensory
function
grossly intact, symmetric palate elevation
SKIN: No significant rashes
DISCHARGE PHYSICAL EXAM:
___ ___ Temp: 98.3 PO BP: 135/84 HR: 71 RR: 18 O2 sat: 99%
GENERAL: Pleasant, lying in bed comfortably
HEENT: NC/AT EOMI MMM sclera nonicteric
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: BS+ nondistended. Moderate TTP in RLQ without rebound or
guarding; + Rovsing sign
BACK: No CVA tenderness
EXT: Warm, well perfused, trace bilat ankle edema
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: Alert, oriented
SKIN: No significant rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 12:32PM URINE HOURS-RANDOM
___ 12:32PM URINE UCG-NEGATIVE
___ 12:32PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 12:32PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-SM*
___ 12:32PM URINE RBC-4* WBC-11* BACTERIA-MOD* YEAST-NONE
EPI-5
___ 12:32PM URINE MUCOUS-RARE*
___ 12:30PM GLUCOSE-87 UREA N-10 CREAT-1.1 SODIUM-136
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-21* ANION GAP-12
___ 12:30PM estGFR-Using this
___ 12:30PM ALT(SGPT)-14 AST(SGOT)-26 ALK PHOS-45 TOT
BILI-0.3
___ 12:30PM LIPASE-34
___ 12:30PM ALBUMIN-4.1 CALCIUM-9.5 PHOSPHATE-3.4
MAGNESIUM-2.0
___ 12:30PM CRP-7.4*
___ 12:30PM WBC-6.0 RBC-4.95 HGB-14.1 HCT-41.8 MCV-84
MCH-28.5 MCHC-33.7 RDW-11.8 RDWSD-35.6
___ 12:30PM NEUTS-53.7 ___ MONOS-9.5 EOS-0.5*
BASOS-0.5 IM ___ AbsNeut-3.21 AbsLymp-2.13 AbsMono-0.57
AbsEos-0.03* AbsBaso-0.03
___ 12:30PM PLT COUNT-196
PERTINENT RESULTS:
==================
___ Gastroenterology Colonoscopy
Normal mucosa in the whole colon and 15cm into the terminal
ileum.
MAC anesthesia for future endoscopies.
DISCHARGE LABS:
===============
___ 05:40AM BLOOD WBC-5.7 RBC-4.38 Hgb-12.5 Hct-36.8 MCV-84
MCH-28.5 MCHC-34.0 RDW-11.8 RDWSD-35.8 Plt ___
___ 05:40AM BLOOD Glucose-89 UreaN-8 Creat-1.2* Na-139
K-3.8 Cl-108 HCO3-21* AnGap-10
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Norethindrone-Estradiol 1 TAB PO DAILY
2. Ciprofloxacin HCl 500 mg PO Q12H
3. MetroNIDAZOLE 500 mg PO BID
Discharge Medications:
1. DICYCLOMine 10 mg PO TID:PRN cramps
RX *dicyclomine 10 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*1
2. Ondansetron ODT 4 mg PO Q6H
RX *ondansetron 4 mg 1 tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*0
3. Norethindrone-Estradiol 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
ABDOMINAL PAIN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with abdominal pain// Eval for signs of bowel
obstruction or free air
TECHNIQUE: Supine and upright AP views of the abdomen
COMPARISON: None.
FINDINGS:
A nonobstructive bowel gas pattern is present. Air is seen within scattered
nondilated loops of large and small bowel. Moderate amount of stool is noted
throughout the colon. No differential air-fluid levels, free intraperitoneal
air, or concerning soft tissue calcifications are evident. No acute osseous
abnormality. Umbilical piercing is incidentally noted.
IMPRESSION:
No evidence for bowel obstruction or free intraperitoneal air.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Nausea
Diagnosed with Other specified noninfective gastroenteritis and colitis, Right lower quadrant pain, Unspecified abdominal pain
temperature: 97.4
heartrate: 67.0
resprate: 18.0
o2sat: 98.0
sbp: 138.0
dbp: 67.0
level of pain: 8
level of acuity: 3.0 | Dear Ms. ___,
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted because you were having abdominal pain which
was concerning and not responding to antibiotics you had
previously taken
WHAT WAS DONE FOR ME WHILE I WAS HERE?
- You underwent a colonoscopy, which was normal. Biopsies were
taken and we are awaiting those results
WHAT DO I NEED TO DO WHEN I LEAVE THE HOSPITAL?
- Please keep your appointments as listed below
- The gastrointestinal department will call you to inform you
about your biopsies
- You do not need to continue taking antibiotics
- You have an MRI scheduled for ___ to help evaluate any
GI issues
We wish you the best with your health,
- Your ___ team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
apples
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: Upper EUS
___: Laparoscopic cholecystectomy
History of Present Illness:
___ w depression who presents with abdominal pain. Pt was
in USOH until 3d ago when had sudden onset of severe abdominal
pain in epigastrum/RUQ/LUQ which radiates into back bilaterally.
Never had before, worse with moving around, better when lying
down, severe, radiates up into chest. Associated with episode of
nausea at onset but none since. No vomiting. Is still hungry.
Denies jaundice. TAH in the past, but otherwise no surgeries in
abdomen. No diarrhea or constipation. No jaundice, no dark
urine,
no light stools. No melena/hematochezia. Reports fevers for 2
days up to 103 at home, no chills. Mild HA at times. No
confusion. No sick contacts. No wheeze, no cough. Only pain is
chest is at the same time as the abdominal pain. Does have some
tingling in her arms and face with this abdominal pain. No
dysuria, urgency, back pain (other than above radiation). No
rash, joint pain.
At OSH AVSS. tender epigastrum/RUQ. WBC 11, hct 38, plts 273, ,
Na 140, K 3.9, bicarb 24, AP 316, TB 3.9, AST 233, ALT 296, UA
neg. Was given levo/flagyl, 1L NS.
OSH CT: distended gallbladder with small stones and borderline
wall thickening (c/f early cholecystitis), hepatic steatosis,
small hiatal hernia. No biliary ductal dilatation.
Had an unread HIDA scan.
Transferred to ___. In ___, AVSS. Was seen by surgery who
looked at HIDA and thought she likely has cholecystitis and will
need surgery likely during this admission, recommended admit to
medicine with MRCP, consult ERCP and abx.
She reports no pain now other than when people push on her
abdomen. She is hungry and thirsty.
Past Medical History:
depression
hysterectomy
Social History:
___
Family History:
CAD and DM
otherwise reviewed and non-contributory to current presentation
Physical Exam:
ADMISSION PHYSICAL EXAM:
Constitutional: VS reviewed, NAD
HEENT: eyes anicteric, normal hearing, nose unremarkable, MMM
without exudate
CV: RRR no mrg
Resp: CTAB
GI: soft, mild to mod ttp RUQ, mildly ttp epigastrum and RLQ, +
___, non-distended, NABS, no rebound
GU: no foley
MSK: no obvious synovitis
Ext: wwp, neg edema in BLEs
Skin: no rash grossly visible
Neuro: A&Ox3, DOWB intact, ___ BUE/BLE, SILT BUE/BLE, EOMI, no
droop
Psych: normal affect, pleasant
Discharge Physical Exam:
VS: 98, 121/59, 73, 18, 94%
Gen: A&O x3, lying comfortably in NAD
CV: HRR
Pulm: LS ctab
Abdl soft, NT/ND. Lap sites CDI
Ext: no edema
Pertinent Results:
ADMISSION LABS:
=============
___ 10:07PM BLOOD WBC-8.7 RBC-3.69* Hgb-11.4 Hct-35.6
MCV-97 MCH-30.9 MCHC-32.0 RDW-13.8 RDWSD-49.2* Plt ___
___ 10:07PM BLOOD Neuts-74.1* Lymphs-13.2* Monos-7.9
Eos-4.0 Baso-0.5 Im ___ AbsNeut-6.46* AbsLymp-1.15*
AbsMono-0.69 AbsEos-0.35 AbsBaso-0.04
___ 09:00AM BLOOD ___ PTT-29.7 ___
___ 10:07PM BLOOD Glucose-104* UreaN-8 Creat-0.8 Na-142
K-4.8 Cl-109* HCO3-19* AnGap-14
___ 10:07PM BLOOD ALT-221* AST-196* AlkPhos-294*
TotBili-2.6* DirBili-1.5* IndBili-1.1
___ 10:07PM BLOOD cTropnT-<0.01
___ 10:07PM BLOOD Albumin-3.6
___ 10:20PM BLOOD Lactate-1.1
IMAGING/STUDIES:
================
___ CXR:
The cardiac silhouette is within normal limits and there
is no evidence of vascular congestion, pleural effusion, or
acute focal
pneumonia. Specifically, no evidence of pneumothorax.
___ Upper EUS:
Impression:No evidence of a CBD stone at present. However, a
passed CBD stone appears most likely clinically.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. lithium carbonate 450 mg oral QHS
2. ALPRAZolam 0.5 mg PO QAM
3. ALPRAZolam 1 mg PO QHS
4. Mirtazapine 15 mg PO QHS
5. DULoxetine 40 mg PO DAILY
6. Vitamin D Dose is Unknown PO DAILY
7. Fluticasone Propionate NASAL 1 SPRY NU BID
8. Furosemide 20 mg PO DAILY:PRN swelling
9. Omeprazole 40 mg PO DAILY
10. rOPINIRole 1 mg PO QPM
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*15 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth once a
day Disp #*14 Packet Refills:*0
5. Vitamin D 1000 UNIT PO DAILY
6. ALPRAZolam 0.5 mg PO QAM
7. ALPRAZolam 1 mg PO QHS
8. DULoxetine 40 mg PO DAILY
9. Fluticasone Propionate NASAL 1 SPRY NU BID
10. Furosemide 20 mg PO DAILY:PRN swelling
11. Lithium Carbonate 450 mg oral QHS
12. Mirtazapine 15 mg PO QHS
13. Omeprazole 40 mg PO DAILY
14. rOPINIRole 1 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with abd pain, fever// r/o ptx, pna
IMPRESSION:
No previous images. The cardiac silhouette is within normal limits and there
is no evidence of vascular congestion, pleural effusion, or acute focal
pneumonia. Specifically, no evidence of pneumothorax.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with Cholangitis, Right upper quadrant pain
temperature: 98.0
heartrate: 81.0
resprate: 16.0
o2sat: 98.0
sbp: 129.0
dbp: 62.0
level of pain: 0
level of acuity: 3.0 | You were admitted to the hospital with acute cholecystitis. You
underwent an endoscopic ultrasound to rule out common bile duct
stones, of which there were none. 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.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / nifedipine / Lipitor
Attending: ___.
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ ___ speaking female with a
history of benign paroxysmal positional vertigo, afib on
Flecainide, atrial flutter s/p ablation, DM, and HTN presenting
with altered mental status.
She had an admission for similar concerns ___ weeks ago with a
negative workup which included: "CT head without any evidence of
CVA. CXR without pneumonia. EKG was without acute changes and
troponin was negative. Vit B12 level normal, RPR negative. TSH
was 0.13 consistent with prior labs and Free T4 pending on
discharge."
She is interviewed with her son, ___, who is translating. She
is unaware of any issues with confusion. Her only complaint is
her usual arthritis pain. She denies fevers or chills. No
changes in urination or bowel movements but does have some
urinary frequency. No headaches or vision changes. Sometimes she
feels weak in her legs or gets twitching in her hands. She has
noticed that she will drop things (like a towel) after picking
them up and this seems to happen more frequently in the last
several weeks.
Normal appetite
The son notes that she was completely normal 3 months ago. She
has episodes of confusion and bizarre behavior (trying to put
pants on as a shirt, not realizing she was not wearing pants,
using the TV remote as a phone). He also thinks she has had some
clumsiness and decreased hand strength (like when picking up a
tea pot) and is more "wobbly" when walking. She also has trouble
with short term memory loss (like being unable to remember what
she ate for breakfast). No obvious personality changes but she
seems to get frustrated more easily.
In between these episodes, she has periods where she still
seems completely normal.
She also has bruising on her stomach and behind her arms. This
is not new but has happened again in the last few weeks. No
obvious trauma but may have fallen out of bed several days ago.
Per ED report, there was some concern over SI. In discussion
with the son, the patient was expressing that she is tired of
being sick all the time and going to the hospital. She felt like
there was no help for her and wanted to give up.
In the ED, initial vitals were: 98.2 67 121/71 18 89% RA
Labs notable for: Negative toxicology screen, Plt 98, Cr 1.5,
Bicarb 16, Glu 291, Lactate 2.1.
Patient was given:
___ 21:32 IVF 1000 mL LR 1000 mL
On the floor, she is well appearing and able to answer
questions appropriately.
ROS: Per HPI
Past Medical History:
- Atrial fibrillation
- Mitral regurgitation
- Atrial flutter w/ resultant ventricular tachycardia: s/p
ablation
- Diabetes
- Peripheral arterial disease
- HTN
- HLD
- Thyroid CA - s/p total thyroidectomy on ___ -
multifocal papillary carcinoma of the thyroid, follicular
variant, in the left lobe of the thyroid.
- Endometrial cancer - s/p TAH-BSO ___, pelvic XRT
- Bilateral knee DJD s/p L TKR
- CKD
Social History:
___
Family History:
mother - uterine ca
No family history of heart disease.
Physical Exam:
ADMISSION EXAM
Vital Signs: T 98.1, BP 124/64, HR 70, RR 18, O2 99/RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
murmur
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, steady gait.
DISCHARGE EXAM
Vitals 98.0 118-124/59-63 59-66 18 100RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
patient has normal gait and is AOx3
Pertinent Results:
ADMISSION LABS
___ 02:25PM BLOOD WBC-5.5 RBC-4.80 Hgb-12.6 Hct-41.7 MCV-87
MCH-26.3 MCHC-30.2* RDW-16.9* RDWSD-53.5* Plt Ct-98*
___ 06:40AM BLOOD ___ PTT-35.8 ___
___ 02:25PM BLOOD Glucose-291* UreaN-25* Creat-1.5* Na-139
K-4.6 Cl-109* HCO3-16* AnGap-19
___ 06:40AM BLOOD ALT-19 AST-33 LD(LDH)-238 AlkPhos-126*
TotBili-0.9
___ 06:40AM BLOOD Albumin-3.5 Calcium-9.5 Phos-3.3 Mg-2.3
___ 06:40AM BLOOD TSH-0.20*
___ 06:40AM BLOOD Free T4-1.7
DISCHARGE LABS
___ 06:30AM BLOOD WBC-3.9* RBC-4.02 Hgb-10.9* Hct-34.1
MCV-85 MCH-27.1 MCHC-32.0 RDW-16.5* RDWSD-50.9* Plt Ct-83*
___ 06:30AM BLOOD Glucose-167* UreaN-26* Creat-1.5* Na-141
K-4.0 Cl-108 HCO3-24 AnGap-13
___ 06:30AM BLOOD ALT-29 AST-49* LD(LDH)-239 AlkPhos-148*
TotBili-1.0
___ 06:30AM BLOOD Albumin-3.6 Calcium-9.5 Phos-3.9 Mg-2.3
MICROBIOLOGY:
___ ___ negative
IMAGING & STUDIES: None.
CT HEAD
No hemorrhage or evidence of acute infarct. Probable sequelae
of chronic small vessel ischemic disease.
CXR
No acute cardiopulmonary process.
MRI/MRA HEAD ___. Motion artifact degrades space resolution.
2. Patchy periventricular and subcortical white matter FLAIR
hyperintensity, likely reflecting sequela chronic
microangiopathy.
3. No acute intracranial abnormality without infarct,
hemorrhage, or mass.
4. Patent intracranial and neck vasculature, without carotid
stenosis by NASCET criteria.
5. T1 hyperintensity within the bilateral basal ganglia which is
a nonspecific finding which may be seen in the setting of liver
disease, hyperglycemia, and parenteral nutrition, amongst
others. Given reported intermittent consider episodic hepatic
encephalopathy. Recommend clinical correlation
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with delirium // eval ? infiltrate, edema
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
The patient arterial no focal consolidation is seen. No pleural effusion or
pneumothorax. The cardiac and mediastinal silhouettes are stable.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ woman with confusion. Evaluate for hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: Head CT dated ___.
FINDINGS:
No evidence of acute infarction, hemorrhage, edema, or mass effect.
Periventricular and subcortical white matter hypodensities are nonspecific and
likely sequelae of chronic small vessel ischemic disease, unchanged. The
ventricles and sulci are normal in size and configuration.
Mild to moderate bilateral cavernous internal carotid calcifications are
unchanged.
No evidence of fracture. Mucosal thickening in the bilateral posterior
ethmoidal air cells is mild. The right frontal sinus is hypoplastic. The
visualized portion of the remaining paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
No hemorrhage or evidence of acute infarct. Probable sequelae of chronic
small vessel ischemic disease.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK PT11 MR ___
INDICATION: ___ year old woman with recurrent brief episodes of confusion; CT
Head negative, infectious work up negative // vascular process or other to
explain AMS.
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain with maximum intensity projection reconstructions.
Dynamic MRA of the neck was performed during administration of 18 mL of
Multihance intravenous contrast.
Brain imaging was performed with sagittal T1 and axial FLAIR, T2, gradient
echo and diffusion technique.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images. The
examination was performed using a 1.5T MRI.
COMPARISON: ___ head CT. ___ head MRI.
FINDINGS:
Study is moderately degraded by motion, especially on postcontrast imaging.
MRI HEAD:
There is patchy periventricular and subcortical white matter FLAIR
hyperintensity, which is nonspecific but likely secondary to sequela of
chronic microangiopathy. There is no evidence of infarct, hemorrhage, mass,
or mass effect. There is T1 hyperintensity within the bilateral basal
ganglia. There is no abnormal parenchymal enhancement. The ventricles and
cortical sulci are normal in caliber configuration. The extra-axial spaces
are unremarkable. The vascular flow voids are preserved.
The orbits, soft tissues, and calvarium are unremarkable. There is mild
mucosal thickening within the paranasal sinuses. There is no abnormal fluid
signal within the mastoid air cells or middle ears.
MRA HEAD:
There is motion artifact which degrades spatial resolution.
The bilateral intracranial internal carotid arteries are patent. The anterior
communicating artery is visualized. The bilateral posterior communicating
arteries are not definitively seen. There are codominant vertebral arteries.
There is segmental low signal within the right V3 and inferior V4 segments of
the right vertebral artery which is patent on the subsequent dynamic neck MRA,
therefore consistent with artifact. The anterior and posterior arterial
circulations are patent without occlusion, dissection, stenosis, or aneurysm.
There is no evidence of vascular malformation.
MRA NECK:
There is a 3 vessel aortic arch. The carotid arteries are patent without
stenosis by NASCET criteria. The vertebral arteries are patent. There is
normal venous contrast enhancement.
IMPRESSION:
1. Study is moderately degraded by motion.
2. Probable small vessel ischemic changes as described.
3. No acute intracranial abnormality without infarct, hemorrhage, or mass.
4. Grossly patent intracranial and cervical vasculature, without carotid
stenosis by NASCET criteria.
5. Nonspecific bilateral basal ganglia findings as described. Differential
considerations include liver disease, hyperglycemia, and parenteral nutrition.
Question episodic hepatic encephalopathy. Recommend correlation with hepatic
function testing.
RECOMMENDATION(S): Nonspecific bilateral basal ganglia findings as described.
Differential considerations include liver disease, hyperglycemia, and
parenteral nutrition. Question episodic hepatic encephalopathy. Recommend
correlation with hepatic function testing.
Gender: F
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Altered mental status
Diagnosed with Altered mental status, unspecified
temperature: 98.2
heartrate: 67.0
resprate: 18.0
o2sat: 99.0
sbp: 121.0
dbp: 71.0
level of pain: 0
level of acuity: 3.0 | Ms. ___,
You were hospitalized for recurrent episodes of confusion
experienced at home. Thankfully your mental status was normal
in the hospital. We obtained an MRI of your brain which did not
show findings to explain your confusion. You should continue to
see either your primary care doctor or ___ neurologist to
determine the cause of the intermittent confusion.
Please follow up with your PCP by calling the number listed
below. If you wish, you can establish care with our primary
care clinic by calling the number listed below. We have also
provided the number to the neurology clinic.
Maintaining a regular sleep schedule can be very helpful in
avoiding these episodes of confusion. When you wake up in the
morning, try to make sure that you are exposed to bright light
and sunshine. Try to avoid taking naps during the day or
drinking caffeinated beverages such as tea or coffee in the
afternoon or evening. We have written a prescription for a
medication that may provide relief from the discomfort in your
legs that happens at night.
It was a pleasure taking care of you!
Your ___ team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lactose
Attending: ___.
Chief Complaint:
Mechanical fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with Parkinsons disease (nonverbal at baseline), HTN, HLD
had a witnessed mechanical fall at her nursing home and is now
presenting from an OSH with concern for ICH on ___.
Per nursing home documentation, the patient was being
transferred to her wheelchair by staff and experienced a
mechanical fall. No loss of consciousness or seizure. +
Headstrike. She was noted to be at her baseline neurologic
status thereafter. She was then taken to ___, where CT
scan of the head showed small cortical ICH and intrafalcine
blood without shift.
Patient is essentially nonverbal and is unable to provide
further history.
In the ___ initial vitals were: 98.1 110 121/76 18 96% RA. Pt
spiked temp to 101.6. HR stayed in the 100s.
- Labs were significant for positive UA, Na 146, normal lactate.
- CXR showed RLL opacity felt to be atelectasis.
- Patient was given 1g IV CTX. Blood cultures drawn.
- Neurosurgery was consulted who said no need for surgical
intervention at this time.
Vitals prior to transfer were: 98.9 109 141/78 23 98% RA.
On arrival to the floor, pt is able to give a thumbs down when
asked if her head hurts or if she has any pain.
Past Medical History:
# ICH (___) s/p fall
# Hypertension
# Hyperlipidemia
# Breast CA s/p breast-conserving surgery followed by
postoperative XRT with arimidex therapy
# Stasis dermatitis with ulceration and previous cellulitis
# Hip fracture
# Gait disorder
# Speech disorder
# CKD
# Osteoarthritis
# Skin cancer
Social History:
___
Family History:
Negative for breast and ovarian cancer.
Physical Exam:
ADMISSION PE:
Vitals: 98, 136/58, 113, 25, 99% on 3L
GENERAL: NAD, resting comfortably in bed, interactive,
cooperates with exam, following commands. Makes noises with her
lips but is unable to speak.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: exam limited. clear anterolaterally. no wheezes, rales,
rhonchi, breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII grossly intact. moving all extremities with
purpose. resting tremor and cogwheel rigidity in the b/l UEs.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PE:
Vitals: 98.3; 150/71; 92; 22; 93RA
Otherwise unchanged exam
Pertinent Results:
ADMISSION LABS:
___ 02:45PM BLOOD WBC-7.3 RBC-3.65* Hgb-12.0 Hct-36.6
MCV-100* MCH-32.8* MCHC-32.7 RDW-14.5 Plt ___
___ 02:45PM BLOOD ___ PTT-27.8 ___
___ 02:45PM BLOOD Glucose-95 UreaN-19 Creat-1.0 Na-146*
K-4.1 Cl-110* HCO3-24 AnGap-16
___ 02:45PM BLOOD Calcium-9.4 Phos-2.8 Mg-1.9
DISCHARGE LABS:
___ 07:00AM BLOOD WBC-4.4 RBC-3.30* Hgb-10.7* Hct-33.1*
MCV-100* MCH-32.3* MCHC-32.2 RDW-14.5 Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-86 UreaN-14 Creat-0.8 Na-146*
K-4.5 Cl-110* HCO3-25 AnGap-16
___ 07:00AM BLOOD Calcium-9.2 Phos-3.0 Mg-1.8
MICRO:
Blood Cx/Urine Cx pending at discharge
Studies/Imaging:
CT Head: OSH imaging report
CXR:
Low lung volumes with right lung opacity laterally potentially
atelectasis although clinical correlation is suggested regarding
possibility of infection. Otherwise no evidence of acute
cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Cyanocobalamin 100 mcg PO DAILY
3. Loratadine 10 mg PO DAILY
4. Polyethylene Glycol 17 g PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. Acetaminophen 650 mg PO Q6H:PRN pain or fever
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Acidophilus (L.acidoph & ___
acidophilus) oral BID
9. Guaifenesin ER 1200 mg PO Q12H
10. Sinemet (carbidopa-levodopa) ___ mg oral TID
11. Docusate Sodium 100 mg PO BID
12. Ferrous Sulfate 325 mg PO DAILY
13. Simvastatin 20 mg PO DAILY
14. Atenolol 50 mg PO DAILY
15. Senna 8.6 mg PO DAILY:PRN constipation
16. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN wheeze
17. LOPERamide 2 mg PO QID:PRN loose stool
18. Benzonatate 200 mg PO TID:PRN cough
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain or fever
2. Aspirin 325 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Benzonatate 200 mg PO TID:PRN cough
5. Cyanocobalamin 100 mcg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Ferrous Sulfate 325 mg PO DAILY
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. Guaifenesin ER 1200 mg PO Q12H
10. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN wheeze
11. Loratadine 10 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY
13. Simvastatin 20 mg PO DAILY
14. Vitamin D ___ UNIT PO DAILY
15. Acidophilus (L.acidoph &
___ acidophilus) 0 ORAL BID
16. LOPERamide 2 mg PO QID:PRN loose stool
17. Senna 8.6 mg PO DAILY:PRN constipation
18. Sinemet (carbidopa-levodopa) ___ mg oral TID
19. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 1 Day
2 doses for ___
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*2 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Intracerebral Hemorrhage
Secondary Diagnosis:
- Parkinsons
- Hyperlipidemia
- Hypertension
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with fall, fever // presence of infiltrate
TECHNIQUE: AP and lateral views of the chest.
COMPARISON: ___ chest x-ray and left humerus films from ___.
FINDINGS:
Low lung volumes are noted with secondary crowding of the bronchovascular
markings. Right midlung opacity seen laterally could potentially represent
atelectasis. There is no effusion or pulmonary edema. The cardiomediastinal
silhouette is within normal limits. Atherosclerotic calcifications noted at
the aortic arch with tortuosity of the descending thoracic aorta. Chronic
changes seen at the proximal left humerus which is incompletely visualized,
suggestive of Paget's disease as on prior dedicated views.
IMPRESSION:
Low lung volumes with right lung opacity laterally potentially atelectasis
although clinical correlation is suggested regarding possibility of infection.
Otherwise no evidence of acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Head injury
Diagnosed with BRAIN HEM NEC W/O COMA, FALL RESULTING IN STRIKING AGAINST OTHER OBJECT, URIN TRACT INFECTION NOS, PARKINSON'S DISEASE
temperature: 98.1
heartrate: 110.0
resprate: 18.0
o2sat: 96.0
sbp: 121.0
dbp: 76.0
level of pain: 13
level of acuity: 2.0 | Dear Ms. ___,
It was a pleasure taking care of you during your
hospitalization. You were admitted for a possible head bleed
after a fall at home. A Ct of your head was performed that
showed two very small hemorrhages. Neurosurgery was consulted
and felt that you did not require surgical intervention. You
will need to follow up in 4 weeks with Dr. ___
have a repeat CT prior to that visit. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weight loss
Major Surgical or Invasive Procedure:
EGD/Colonoscopy
History of Present Illness:
___ F with hx depression, HTN, alpha thalassemia trait
(baseline
Hgb 10.7) and HFrEF (43%) presenting from clinic after noted ___
on labs iso dizziness, nausea, weakness, and abdominal pain.
She had been having one month of dizziness, lightheadedness, and
L sided abdominal pain as well as diffuse weakness and nausea
with 1 episode of vomiting. Due to her nausea, she reports that
she has been having poor PO intake. The dizziness worse upon
standing. When she eats, she feels full and bloated and has
vague
left abdominal pain. She reports loose stools but no diarrhea.
She endorses SOB concurrent with her dizziness, but no DOE,
chest
pain, orthopnea, ___ edema. She also endorses a dry cough for
the last few days but denies congestion, sore throat, fevers,
chills, palpitations, black/bloody stools, or changes in stool
caliber. She reports having dysuria a few times a day. She has
unintentionally lost 23 lbs since ___. Of note, she was
supposed to have a colonoscopy but did not because she was too
weak. She went to her PCP ___ ___, and given a BP of 79/48 in
clinic, her home lisinopril and carvedilol were held. She had
labs drawn and was found to have Cr of 2.79 (baseline Cr 0.8),
so
her PCP called her and asked that she present to the ED.
In the ED:
Her vital signs were notable for: Afebrile (97.6F), HR 77, BP
103/80 initially but dropped to 82/46 and recovered to 102/58
with IVFs, RR 18, 98% on room air
Exam notable for: conjunctival pallor, clear lungs, no ___ edema,
no CVA tenderness
Labs were notable for: Na 134, Hgb 8.3, no leukocytosis, lactate
of 2.6, urine electrolytes with Na<20, proBNP 310, UA negative,
and blood/urine cultures were obtained
Studies performed include: Renal U/S wnl
EKG: normal sinus rhythm with no ischemic changes, QTc 460
Patient was given 3L IVF with downtrend in lactate from 2.6 to
1.9.
ED consults: Nephrology
Upon arrival to the floor, she reports feeling much better
without any dizziness s/p fluids. She denies any pain, including
abdominal pain, and is not currently nauseous.
Past Medical History:
-HTN (baseline on treatment is 120s-130s/80 in clinic)
-HFrEF
-arthritis
-anemia
-depression
-Anal fissure
-Hemorrhoids
-Alpha thalassemia trait
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 97.9 HR 64 BP 131/76 RR 18 SpO2 99% on room air
GENERAL: Alert and interactive, well appearing sitting in bed
HEENT: PERRL, EOMI. Sclera anicteric and without injection. Good
dentition
NECK: JVD not appreciated
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. Symmetric chest excursion
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Soft, nontender, nondistended. No organomegaly. Loose,
extra skin c/w weight loss
EXTREMITIES: Warm and well perfused, DP/Radial 2+ bilaterally.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Speech is
fluent with no gross deficits. Pleasant and warm affect
DISCHARGE PHYSICAL EXAM:
Vitals: 24 HR Data (last updated ___ @ 827)
Temp: 98.6 (Tm 98.6), BP: 124/75 (106-134/69-87), HR: 72
(67-99), RR: 16 (___), O2 sat: 100% (99-100), O2 delivery: Ra,
Wt: 156 lb/70.76 kg
General: Alert and interactive, well appearing, sitting in bed
eating breakfast
HEENT: PERRL, EOMI. Sclera anicteric and without injection. Good
dentition.
Lungs: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
CV: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
GI: Soft, nontender, nondistended. No organomegaly.
Ext: Warm and well perfused, no edema.
Neuro: AOx3, strength and sensation grossly intact.
Pertinent Results:
___ 11:50AM BLOOD WBC-3.7* RBC-3.64* Hgb-8.3* Hct-26.5*
MCV-73* MCH-22.8* MCHC-31.3* RDW-17.2* RDWSD-44.4 Plt ___
___ 07:24AM BLOOD WBC-9.4 RBC-3.20* Hgb-7.4* Hct-23.3*
MCV-73* MCH-23.1* MCHC-31.8* RDW-17.3* RDWSD-44.1 Plt ___
___ 06:15AM BLOOD WBC-4.7 RBC-3.02* Hgb-7.0* Hct-22.4*
MCV-74* MCH-23.2* MCHC-31.3* RDW-17.3* RDWSD-45.8 Plt ___
___ 07:32AM BLOOD ___
___ 07:45AM BLOOD Ret Aut-1.7 Abs Ret-0.06
___ 01:24PM BLOOD Ret Aut-2.1* Abs Ret-0.06
___ 11:50AM BLOOD Glucose-122* UreaN-36* Creat-3.9* Na-134*
K-5.1 Cl-98 HCO3-17* AnGap-19*
___ 07:45AM BLOOD Glucose-96 UreaN-19 Creat-1.3*# Na-144
K-5.2 Cl-112* HCO3-19* AnGap-13
___ 06:15AM BLOOD Glucose-91 UreaN-12 Creat-0.9 Na-140
K-4.3 Cl-101 HCO3-28 AnGap-11
___ 11:50AM BLOOD ALT-17 AST-30 AlkPhos-59 TotBili-0.3
___ 11:50AM BLOOD Lipase-65*
___ 11:50AM BLOOD proBNP-310
___ 11:50AM BLOOD Albumin-4.2 Iron-88
___ 07:24AM BLOOD Hapto-105
___ 07:45AM BLOOD ___ Folate->20 Hapto-70
___ 11:50AM BLOOD calTIBC-281 Ferritn-563* TRF-216
___ 07:45AM BLOOD %HbA1c-5.3 eAG-105
___ 06:15AM BLOOD TSH-2.1
___ 07:45AM BLOOD Cortsol-9.6
___ 06:15AM BLOOD IgA-194
___ 06:15AM BLOOD tTG-IgA-PND
___ 11:50AM BLOOD LtGrnHD-HOLD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ranitidine 150 mg PO QHS
2. Aspirin 81 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Hydrocortisone Cream 2.5% 1 Appl TP BID Anal fissure
5. FLUoxetine 20 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Maalox/Diphenhydramine/Lidocaine Dose is Unknown PO QID:PRN
oral sores
8. amLODIPine 10 mg PO DAILY
9. mometasone 0.1 % topical DAILY
10. clotrimazole-betamethasone ___ % topical BID
11. Senna 8.6 mg PO BID:PRN Constipation - First Line
12. Lisinopril 40 mg PO DAILY
13. Carvedilol 6.25 mg PO BID
Discharge Medications:
1. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN oral
sores
2. Aspirin 81 mg PO DAILY
3. clotrimazole-betamethasone ___ % topical BID
4. FLUoxetine 20 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Hydrocortisone Cream 2.5% 1 Appl TP BID Anal fissure
7. mometasone 0.1 % topical DAILY
8. Multivitamins 1 TAB PO DAILY
9. Ranitidine 150 mg PO QHS
10. Senna 8.6 mg PO BID:PRN Constipation - First Line
11. HELD- amLODIPine 10 mg PO DAILY This medication was held.
Do not restart amLODIPine until your doctor tells you to do so.
12. HELD- Carvedilol 6.25 mg PO BID This medication was held.
Do not restart Carvedilol until your doctor tells you to do so.
13. HELD- Lisinopril 40 mg PO DAILY This medication was held.
Do not restart Lisinopril until your doctor tells you to do so.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Weight loss, unexplained
Incidental renal mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with HTN, depression, anemia, HFrEF presenting
with ___ (baseline 0.8, now 3.7), nausea, dizziness, and hypotension//
bilateral ultrasound with Doppler iso rapidly rising Cr
TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the
kidneys were obtained.
COMPARISON: None.
FINDINGS:
There is no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedulary differentiation are seen bilaterally.
Right kidney: 8.8 cm
Left kidney: 8.7 cm
Renal Doppler: Intrarenal arteries show normal waveforms with sharp systolic
peaks and continuous antegrade diastolic flow. The resistive indices of the
right intra renal arteries range from 0.72-0.8. The resistive indices on the
left range from 0.71-0.75. Bilaterally, the main renal arteries are patent
with normal waveforms. The peak systolic velocity on the right is 60.2
centimeters/second. The peak systolic velocity on the left is 62.1
centimeters/second. Main renal veins are patent bilaterally with normal
waveforms.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
Normal renal ultrasound. No evidence of renal artery stenosis.
Radiology Report
INDICATION: ___ yo female presenting with weight loss and early satiety, got
EGD/colonoscopy this morning and suddenly has fevers/rigors, concern for
aspiration pneumonitis// ? Pneumonitis/pneumonia causing fevers/rigors
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
There is new elevation of the left hemidiaphragm suggestive left lower lobe
atelectasis. Patchy opacities however throughout the left mid lower lung
raise concern for superimposed aspiration/pneumonia. There is no pleural
effusion or pneumothorax. No focal consolidation is seen within the right
lung. The size of the cardiac silhouette is within normal limits. Tortuosity
of the thoracic aorta.
IMPRESSION:
Elevated left hemidiaphragm likely reflect left lower lobe atelectasis. There
are however superimposed ill-defined patchy opacities within the left mid and
lower lung which raise concern for superimposed aspiration/pneumonia.
Radiology Report
EXAMINATION: Abdominal pelvis CT
INDICATION: ___ yo female with h/o HFrEF (EF 43%), alpha thalassemia trait,
HTN who presents with 1 month of dizziness and L abdominal pain iso poor PO
intake with nausea/vomiting, found to have ___ and acute on chronic
microcytic anemia, admitted for workup of FTT/weight loss.// ?malignancy or
other explanation for early satiety and weight loss
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.9 s, 64.7 cm; CTDIvol = 12.2 mGy (Body) DLP = 790.9
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 7.2 s, 0.5 cm; CTDIvol = 40.3 mGy (Body) DLP =
20.1 mGy-cm.
Total DLP (Body) = 813 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Please refer to the chest CT done the same day.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
Small 7 mm lesion at the periphery of segment 8 too small to be characterized.
There is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is a 12 x 10 mm hypodense lesion in the inferior aspect of left the
kidney with indeterminate density (65 ___ unit). There is a 8 mm cyst
in the inferior aspect of the right kidney. There is no perinephric
abnormality. No hydronephrosis.
GASTROINTESTINAL: The stomach is not well-distended which limit the evaluation
of this organ. This is to be correlated to an endoscopy if clinically
pertinent. small bowel loops demonstrate normal caliber, wall thickness, and
enhancement throughout. The colon and rectum are within normal limits. The
appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: 2 cm anterior fundic fibroid and 1 calcified measuring 11
mm in the posterior fundus.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: Degenerative changes in the lower lumbar spine.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
-No acute intra-abdominal process.
-Indeterminate 1.2 cm left renal lesion not seen on the ultrasound done the ___ to be further characterized by MRI.
-
RECOMMENDATION(S): Abdominal MRI to characterize left renal lesion.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: Weight loss. Early satiety. Malignancy or other explanation?
TECHNIQUE: Chest CT with IV contrast.
DOSE: Found no primary dose record and no dose record stored with the sibling
of a split exam.
!If this Fluency report was activated before the completion of the dose
transmission, please reinsert the token called CT DLP Dose to load new data.
COMPARISON: None
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: Unremarkable
UPPER ABDOMEN: Please refer to the abdominal CT done the same day.
MEDIASTINUM: No mediastinal adenopathy. Simple fluid in the superior
pericardial recess which is within normal limits.
HILA: No hilar adenopathy.
HEART and PERICARDIUM: No cardiomegaly. No pericardial effusion.
PLEURA: No pleural effusion
LUNG:
-PARENCHYMA: Nodular ground-glass opacities with a peribronchovascular
distribution predominantly in the lingula and left lower lobe with a
consolidation in the lateral segment of the left lower lobe concerning for
pneumonia.
-AIRWAYS: Patent
-VESSELS: Unremarkable
CHEST CAGE: No worrisome bone lesion.
IMPRESSION:
-No concerning lesion for malignancy.
-Multifocal left lung opacity predominantly in the lingula and the left lower
lobe with consolidation concerning for pneumonitis. follow-up with imaging
post treatment is recommended.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abnormal labs, Dizziness, Weakness
Diagnosed with Hypotension, unspecified, Hypovolemia, Acute kidney failure, unspecified
temperature: 97.6
heartrate: 77.0
resprate: 18.0
o2sat: 98.0
sbp: 103.0
dbp: 80.0
level of pain: 0
level of acuity: 3.0 | Dear Ms. ___,
You were admitted to ___ because you kidneys were damaged and
you had been losing weight.
We did imaging to look for any reason for your decreased
appetite but did not find anything concerning. Your kidneys
improved with hydration.
When you leave the hospital:
- Please follow up with your doctor appointments below
- ___ take note of your medication list below for any changes
- Please try to drink enough water daily and eat as much as
possible so that you do not lose weight or become dehydrated
again
It was a pleasure caring for you! |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Briefly, Mr. ___ was treated in ___ for community
acquired pneumonia with levofloxacin for 7 and subsequently
presented to the ___ ED on ___ with the
sudden onset of fever, chills, shortness of breath. In the ED at
___ he was found to have new atrial fibrillation. He was also
found to be leukopenic with WBC count of 2.68, a Lactate of 4.0
and Troponin 0 0.079. He was initially started with broad
spectrum antibiotics including vancomycin, metronidazole and
cefepime. Blood cultures grew gram-negative diplococci
(speciated as Moraxella catarrhalis sensitive to ceftriaxone)
and TEE showed no evidence of endocarditis and showed normal
valve function. Given no other identifiable source of infection
and high likelihood of endocarditis infectious disease
recommended continuing 6 weeks of IV antibiotics with
ceftriaxone (to end on ___. Further, during this
admission the patient appeared volume overloaded Patient volume
overloaded on physical examination and a TTE revealed new
reduced ejection fraction of 30 to 35%. He was started on
furosemide, lisinopril and his metoprolol increased to 75 mg
daily. Finally, during this admission, the patient was observed
to have paroxysmal atrial fibrillation during first day of
hospital stay, but throughout his stay, telemetry mostly
revealed normal sinus rhythm. His TEE showed left atrial
fibrosis and likely concern for transthyretin amyloidosis. Given
high risk of stroke and paroxysmal atrial fibrillation
cardiology recommended initiating anticoagulation with apixaban.
Patient discharged on apixaban 5 mg twice daily. The patient was
ultimately discharged after a 5 day hospital stay on ___.
The patient presents to ___ complaining of chest pain and
shortness of breath. He reports that he has had dyspnea on
exertion and heaviness in his chest which have worsened over the
last 3 days. His symptoms tend to go away with rest. The patient
reports that these symptoms became increasingly frequent and
severe in the few days leading up to presentation. The patient
described his chest discomfort as a heaviness that did not
radiate and resolved with rest. He denied nausea, vomiting,
diaphoresis and fevers.
In the ED, the patient was asymptomatic an well appearing with
vitals that were all within normal limits. Given his symptoms,
however, there was concern for atypical chest pain/unstable
angina. His EKG showed EKG borderline lateral depressions. Trop
0.04 (of note Trop during hospitalization (~5 weeks ago) peaked
at 0.48). Given concerns about the patient's chest pain,
symptoms, trops, and EKG, he was admitted to cardiology.
On arrival to the floor, the patient is resting comfortably in
bed and appears well. He endorses the above history. He
continues to endorse intermittent shortness of breath and chest
tightness with activity. He denies chest pain currently. He
states that he is extraordinarily fatigued.
Past Medical History:
Heart Failure with Reduced Ejection Fraction
Atrial Fibrillation
Diabetes Mellitus
Mild CAD
Aortic Stenosis s/p AVR
Hypercholesterolemia
History of TIA
BPH
Thalassemia Trait
Carpal tunnel syndrome
Social History:
___
Family History:
Brother: ___ cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: Reviewed in POE
GENERAL: Well appearing elderly male in no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: JVP ~10cm. No thyromegaly. No LAD.
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: Soft, non-tender, non-distended. +Bowel sounds.
EXTREMITIES: Trace to 1+ edema. Pulses DP/Radial 2+ bilaterally.
SKIN: Warm. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. ___ strength throughout. Normal
sensation.
DISCHARGE PHYSICAL EXAM
=========================
Physical Exam:
VS: Temp: 99.1 PO BP: 122/72 R Sitting HR: 79 RR: 18 O2 sat: 98%
O2 delivery: RA FSBG: 130
CV: Regular rhythm. No murmurs, rubs, gallops. Normal S1/S2.
Elevated JVP with distended EJ.
PULM: CTAB. no wheezes/rales. Normal work of breathing.
ABD: Soft, non-distended. Non-tender to palpation.
EXT: Warm and well-perfused. ___ +2 pitting edema to mid-shin
bilaterally, improved from prior.
Pertinent Results:
ADMISSION LABS
___ 09:00PM cTropnT-0.04*
___ 03:47PM CK-MB-3 proBNP-8446*
___ 03:47PM WBC-7.4 RBC-4.07* HGB-9.2* HCT-28.9* MCV-71*
MCH-22.6* MCHC-31.8* RDW-16.1* RDWSD-40.8
___ 03:47PM PLT COUNT-175
___ 03:47PM NEUTS-72.3* LYMPHS-18.3* MONOS-7.5 EOS-1.1
BASOS-0.3 IM ___ AbsNeut-5.36 AbsLymp-1.36 AbsMono-0.56
AbsEos-0.08 AbsBaso-0.02
___ 03:47PM GLUCOSE-130* UREA N-23* CREAT-1.0 SODIUM-131*
POTASSIUM-4.1 CHLORIDE-93* TOTAL CO2-25 ANION GAP-13
___ 03:47PM CALCIUM-8.7 PHOSPHATE-3.5 MAGNESIUM-1.8
DISCHARGE LABS
___ 04:44AM BLOOD WBC-9.0 RBC-4.01* Hgb-9.0* Hct-28.1*
MCV-70* MCH-22.4* MCHC-32.0 RDW-15.7* RDWSD-38.7 Plt ___
___ 04:44AM BLOOD Glucose-134* UreaN-24* Creat-0.9 Na-133*
K-4.1 Cl-94* HCO3-25 AnGap-14
___ 04:44AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.2
MICRO: none
IMAGING: none
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 5 mg PO BID
2. Aspirin 81 mg PO DAILY
3. beclomethasone dipropionate 40 mcg/actuation inhalation BID
4. CefTRIAXone 2 gm IV Q24H
5. Finasteride 5 mg PO DAILY
6. Lisinopril 10 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Pravastatin 40 mg PO QPM
11. Tamsulosin 0.4 mg PO QHS
12. Furosemide 40 mg PO BID
13. Spironolactone 12.5 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
15. Cyanocobalamin 1000 mcg PO DAILY
16. Ascorbic Acid ___ mg PO Frequency is Unknown
Discharge Medications:
1. Torsemide 20 mg PO BID
PLEASE TAKE ONE PILL TWO TIMES PER DAY. THIS WILL MAKE YOU HAVE
TO URINATE.
RX *torsemide 20 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
2. Ascorbic Acid ___ mg PO DAILY
3. Apixaban 5 mg PO BID
4. Aspirin 81 mg PO DAILY
5. beclomethasone dipropionate 40 mcg/actuation inhalation BID
6. CefTRIAXone 2 gm IV Q24H
7. Cyanocobalamin 1000 mcg PO DAILY
8. Finasteride 5 mg PO DAILY
9. Lisinopril 10 mg PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Pravastatin 40 mg PO QPM
14. Spironolactone 12.5 mg PO DAILY
15. Tamsulosin 0.4 mg PO QHS
16. Vitamin D 1000 UNIT PO DAILY
17. HELD- Furosemide 40 mg PO BID This medication was held. Do
not restart Furosemide until your primary care provider tells
you to restart.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Heart failure exacerbation
SECONDARY DIAGNOSIS
===================
Moraxella catarrhalis Bacteremia
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with chest pain, dyspnea, cough// eval pna, volume
overload
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior chest radiographs, most recently ___.
FINDINGS:
No focal consolidation is seen. Trace left pleural effusion. No
pneumothorax. Prominence of the cardiomediastinal silhouette without evidence
of overt edema. Heart size is mildly enlarged. Status post aortic valve
replacement. Median sternotomy wires are present. Left-sided PICC line
appears to terminate in the mid SVC.
IMPRESSION:
1. Trace left pleural effusion; possible trace right pleural effusion.
2. No evidence of overt pulmonary edema. Mild cardiomegaly.
3. Left-sided PICC line terminates in the mid SVC.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain, Dyspnea
Diagnosed with Chest pain, unspecified, Type 2 diabetes mellitus without complications, Unspecified atrial fibrillation
temperature: 96.6
heartrate: 70.0
resprate: 18.0
o2sat: 100.0
sbp: 124.0
dbp: 63.0
level of pain: 0
level of acuity: 2.0 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You came into the hospital because you became short of breath
after climbing stairs. You also experienced some chest
discomfort.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- In the hospital, our team decided that your symptoms were most
consistent with heart failure exacerbation. You were given
medication (Lasix), a diuretic that is meant to reduce fluid
congestion in your lungs which may be causing responsible for
your symptoms.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please continue to take all of your medications and follow-up
with your appointments as listed below. Please discuss your
dosing of your diuretic going forward with your primary care
physician and your cardiologist.
We wish you the best!
Sincerely,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Keflex / Capoten / Calan / Ciprofloxacin /
Pneumococcal Vaccine
Attending: ___.
Chief Complaint:
shortness of breath and fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with history of CAD s/p stent placement x 7,
diastolic CHF (LVEF>55% in ___ and hypertension presents
with fatigue and dyspnea. She noted the shortness of breath
today after waking up from a nap after breakfast. The fatigue
began several weeks ago and has been worsening slowly. Patient
has a recent CHF diagnosis (___). There is no chest pain,
cough, abdominal complaints or fevers.
In the ED, initial vs were: 99.0 81 156/70 20 100% 2L Nasal
Cannula. Labs were remarkable for hematocrit of 24 from baseline
of 32, with MCV of 73. INR was mildly elevated at 1.2. BNP was
1171, troponin was <0.01. Urinalysis was unremarkable. She was
transfused one unit PRBCs over four hours and given 20 mg IV
furosemide. Rectal exam showed normal tone, guaiac negative.
Chest X-ray showed small left pleural effusion (c/w prior) and
mild pulmonary edema. ECG showed normal sinus rhythm, with RBBB
and inferior TWI consistent with prior. Patient has one 18g IV
in right AC. Vitals on Transfer: 98.0 78 151/78 18 100%. On the
floor, vs were: T 98.1 P 80 BP 132/86 R 22 O2 sat 100% on 2L.
Currently, the patient reports her shortness of breath has
improved since arrival to the hospital. Has not noted any blood
in the urine or stool. Denies hematochezia, melena, or BRBPR.
Last bowel movement was this morning and it was normal. Does not
take NSAIDs but uses asprin and plavix. Last colonoscopy was in
___ -- it showed diverticulosis of the sigmoid colon, polyps in
the proximal ascending colon but was otherwiase a normal
colonoscopy.
Denies waking up during the night with shortness of breath. She
normally sleeps in a recliner -- due to problems with getting in
and out of bed with her osteoarthritis. When she naps in bed,
she uses 2 pillows. Follows low salt diet. No worsening of leg
swelling.
Past Medical History:
CATARACTS s/p bilateral cataract surgery
CONGESTIVE HEART FAILURE
CORONARY ARTERY DISEASE: LAD, RCA, LCX drug-eluting stents ___
DIABETES TYPE II -- induced by steroids
Uveitis
HYPERLIPIDEMIA
HYPERTENSION
OSTEOARTHRITIS
VENOUS INSUFFICIENCY s/p failed vein stripping
ANEMIA
PROTEINURIA
MACULAR DEGENERATION
h/o renal artery stenosis
elevated ESR of unclear etiology; autoimmune work up negative
PAST SURGICAL HISTORY:
FEMORAL HERNIA REPAIR
CHOLECYSTECTOMY
Vein stripping in ___
Social History:
___
Family History:
Father with DM2
Mother lived to age ___ non malignant pancreas mass
Brother with bladder cancer
Sister with CVA
Sons with HTN and CAD
Physical Exam:
Physical exam at admission:
T 98.1 P 80 BP 132/86 R 22 O2 sat 100% on 2L.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: +crackles L>R through the mid lung fields; no wheezes,
rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing or cyanosis, +
edema to below level of knees bilaterally
Skin: erythematous violaceous skin changes in bilateral feet to
level of lower calf
Neuro:alert, oriented x3; strenght and sensation symmetric in
upper and lower extremities
GU: foley catheter in place with yellow to clear liquid in
collection box
Physical exam at discharge:
98.5 65 18 180/77 95% on RA
I/0: ___ yesterday
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: +crackles -- scant in bilateral bases, no wheezes or
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing or cyanosis, +
trace edema to level of mid calves
Skin: erythematous violaceous skin changes in bilateral feet to
level of lower calf
Pertinent Results:
Labs at admission:
___ 01:25PM BLOOD WBC-6.7 RBC-3.32* Hgb-7.4*# Hct-24.1*#
MCV-73*# MCH-22.3*# MCHC-30.7* RDW-17.7* Plt ___
___ 01:25PM BLOOD Neuts-74.2* Lymphs-17.6* Monos-6.2
Eos-1.8 Baso-0.2
___ 02:19PM BLOOD ___ PTT-29.9 ___
___ 01:25PM BLOOD Glucose-140* UreaN-20 Creat-1.0 Na-138
K-4.0 Cl-99 HCO3-28 AnGap-15
___ 05:40AM BLOOD ALT-10 AST-24 LD(LDH)-311* AlkPhos-92
TotBili-0.4
___ 01:25PM BLOOD Calcium-8.7 Phos-4.0 Mg-2.1 Iron-20*
Pertinent labs:
___ 01:25PM BLOOD cTropnT-<0.01
___ 01:25PM BLOOD proBNP-1171*
___ 12:04AM BLOOD calTIBC-364 Hapto-236* Ferritn-11*
TRF-280
___ 01:25PM BLOOD calTIBC-368 VitB12-906* Folate-GREATER TH
Ferritn-11* TRF-283
Labs at discharge:
___ 05:50AM BLOOD WBC-8.2 RBC-4.10* Hgb-9.9* Hct-30.7*
MCV-75* MCH-24.3* MCHC-32.3 RDW-18.1* Plt ___
___ 05:50AM BLOOD ___ PTT-30.5 ___
___ 05:50AM BLOOD Glucose-122* UreaN-21* Creat-0.9 Na-139
K-3.4 Cl-98 HCO3-30 AnGap-14
___ 05:50AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.1
Imaging:
CXR ___:
IMPRESSION:
1. Mild interstitial pulmonary edema. No focal consolidation.
2. Moderate cardiomegaly, not significantly changed.
3. Unchanged small left pleural effusion.
EKG ___:
Sinus rhythm. Prolonged A-V conduction. Left axis deviation.
Left
ventricular hypertrophy. Right bundle-branch block. Left
anterior fascicular block. Non-specific inferior T wave
abnormalities. Prolonged A-V conduction. Compared to the
previous tracing of ___ voltage has increased slightly, now
meeting criteria for left ventricular hypertrophy. Otherwise,
findings are similar.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from
PatientFamily/CaregiverwebOMR.
1. Amlodipine 10 mg PO DAILY
2. Atenolol 100 mg PO DAILY
3. bromfenac *NF* 0.09 % ___ 1 drop BID in R eye
4. Clopidogrel 75 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Furosemide 40 mg PO BID
7. GlipiZIDE 5 mg PO DAILY
8. Lisinopril 40 mg PO DAILY
9. Losartan Potassium 50 mg PO DAILY
10. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN breakthrough
hip pain
11. Simvastatin 20 mg PO QHS
12. TraMADOL (Ultram) 50 mg PO Q6H:PRN hip pain
13. Acetaminophen 500 mg PO Q8H:PRN pain
14. Aspirin 81 mg PO DAILY
15. Ranitidine 150 mg PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q8H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atenolol 100 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. Losartan Potassium 50 mg PO DAILY
9. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN breakthrough
hip pain
10. Ranitidine 150 mg PO DAILY
11. Simvastatin 20 mg PO QHS
12. TraMADOL (Ultram) 50 mg PO Q6H:PRN hip pain
13. Bisacodyl 10 mg PO DAILY
RX *bisacodyl 5 mg 1 tablet(s) by mouth as needed daily for
constipation Disp #*30 Tablet Refills:*0
14. Ferrous Sulfate 325 mg PO TID
Please give with orange juice.
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
three time a day Disp #*90 Tablet Refills:*0
15. Senna 2 TAB PO HS
Patient may refuse. Hold if patient has loose stools.
RX *sennosides 8.6 mg 1 tablet by mouth daily as needed for
constipation Disp #*30 Tablet Refills:*0
16. bromfenac *NF* 0.09 % ___ 1 drop BID in R eye
17. Furosemide 40 mg PO DAILY
18. GlipiZIDE 5 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Iron deficiency anemia
Secondary:
Diastolic heart failure
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: Shortness of breath and cough.
COMPARISON: Chest radiograph from ___.
FINDINGS: Frontal and lateral radiographs of the chest were acquired. There
is a diffuse interstitial abnormality, with a perihilar predominance,
suggestive of mild interstitial pulmonary edema. Moderate enlargement of the
cardiac silhouette is not significantly changed. A small left pleural
effusion is not significantly changed. There is no definite right pleural
effusion. The mediastinal contours are unchanged. There is a small hiatal
hernia, not significantly changed. There is no pneumothorax. Surgical clips
project over the upper abdomen on the lateral radiograph. Multilevel
degenerative changes of the thoracolumbar spine are noted. Anterior wedging
of a lower thoracic vertebral body is not significantly changed.
IMPRESSION:
1. Mild interstitial pulmonary edema. No focal consolidation.
2. Moderate cardiomegaly, not significantly changed.
3. Unchanged small left pleural effusion.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: SHORTNESS OF BREATH
Diagnosed with ANEMIA NOS, CONGESTIVE HEART FAILURE, UNSPEC, CAD UNSPEC VESSEL, NATIVE OR GRAFT
temperature: 99.0
heartrate: 81.0
resprate: 20.0
o2sat: 100.0
sbp: 156.0
dbp: 70.0
level of pain: 0
level of acuity: 3.0 | it was a pleasure to participate in your care at ___
___. You came to the hospital because of
fatigue and shortness of breath. We found that you have anemia
-- which means you have a low red blood cell count. You anemia
is due to having lower iron in your body. We gave you blood
transfusions which helped increase your red blood cell count.
We also found that you had extra fluid in your body. We gave
you lasix through your IV to help with this. Weigh yourself
every morning, call MD if weight goes up or down by more than 3
lbs.
Please take all of your medications as prescribed. You will
need to take iron pills when you leave the hospital. Take the
pills with orange juice. You should also take a stool softer
while taking the iron pills.
Please keep all follow up appointments. You and your primary
care doctor can discuss further investigating the cause of the
low iron in your body. Please be sure discuss with your doctor
if you would like further tests to look for sources of bleeding
such as a colonoscopy.
Lastly, you were given a flu shot prior to discharge. You may
have arm soreness for the next ___ hours. Please take tylenol
___ every 4 hours as needed for pain. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Hip Pain
Major Surgical or Invasive Procedure:
Hip Fixation with 7.3-mm cannulated screws
History of Present Illness:
___ yo F with h/o Ulcerative proctitis on prednisone, recent PE
on coumadin, GERD, osteoporosis presents with R hip and ankle
pain after a fall. Had been seated in a recliner for several
hours, went to stand up but leg was 'asleep' and fell down onto
R hip and twisted R ankle. No other injuries (specifically
denies head injury, neck injury). No syncope, no preceeding LH,
dizziness, CP, SOB. PMH notable for ulcerative proctitis with
chronic anemia. Of NOte the patient had symptomatic PE 2 months
ago after prolonged airline travel and is currently being
treated with warfarin last inr of 1.5 on ___, and also has
chronic prednisone use of ulcerative proctitis. Which she says
she is on a taper for.
ED COURSE:
triage v/s ___ 56 142/82 20 99% ra
Labs pertinent for
chem 141/3.9; 105/24; ___ <86
cbc 8.7>35.6 (b/l 39) <311
ECG: sinus at 84, RBBB with NSST, no sign change from ___
radigraphs: + R hip femur fracture.
Ortho was consulted, because of complicated medical issues was
admitted to medicine.
Pt received 4mg IV morphine for pain control.
On the floor pt complains of right sided hip pain but no other
complaints. Pain is ___ when lying still and ___ with any
movement.
ROS: positive for some shortness of breath
No chest pain, light headedness, dizziness, numbness, tingling,
Past Medical History:
Ulcerative proctitis on Colonoscopy ___
Shingles ___ waiste right side
cholecystectomy
appendectomy
umbilical hernia times two
surgery for tubal pregnancy.
Vertigo.
Hearing loss.
Osteoporosis.
Chronic low back pain.
GERD.
Hypercholesteremia.
vestibular neuritis
Zoster vaccine ___
Social History:
___
Family History:
No history of UC.
Physical Exam:
ADMISSION PHYSICAL EXAM
98.2 131/71 96 20 100%RA
GENERAL - ___ female unfocomfortable with leg pain
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, Dry MM, OP clear
NECK - supple, no thyromegaly, JVD not assesed, no carotid
bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWPM no C/E/E. Right hip very TTP. No ecchymoses
or gross defomrities.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ in UE. ___ not checked ___ pain. Sensation grossly intact
throughout,
DISCHARGE PHYSICAL EXAM
T98.3| BP 150/84| HR 91| RR 18 satting 100% on RA
GENERAL - ___ female unfocomfortable with right hip pain
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, JVD not assesed, no carotid
bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWPM no C/E/E. Right hip wound CDI. No bleeding.
Minimal erythema. No ecchymoses. Tender.
NEURO - awake, A&Ox3, able to converse and do days of week
backwards, CNs II-XII grossly intact, muscle strength ___ in UE.
___ not checked ___ pain. Sensation grossly intact
throughout.
Pertinent Results:
___ 11:15PM BLOOD WBC-8.7 RBC-4.40 Hgb-12.1 Hct-35.6*
MCV-81* MCH-27.6 MCHC-34.1 RDW-14.1 Plt ___
___ 11:15PM BLOOD Neuts-71.6* ___ Monos-6.6 Eos-0.5
Baso-0.4
___ 11:15PM BLOOD ___ PTT-37.5* ___
___ 11:15PM BLOOD Glucose-86 UreaN-16 Creat-0.7 Na-141
K-3.9 Cl-105 HCO3-24 AnGap-16
___ 03:32AM BLOOD WBC-6.2 RBC-3.49* Hgb-9.8* Hct-29.2*
MCV-84 MCH-28.0 MCHC-33.5 RDW-14.8 Plt ___
___ 08:50AM BLOOD PTT-72.7*
___ 03:32AM BLOOD Plt ___
___ 03:32AM BLOOD ___ PTT-73.4* ___
___ 03:32AM BLOOD Glucose-92 UreaN-9 Creat-0.6 Na-141 K-3.7
Cl-109* HCO3-25 AnGap-11
___ 03:32AM BLOOD Phos-3.3 Mg-2.0
___ 11:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
___ 11:15PM URINE Color-Straw Appear-Hazy Sp ___
EKG ___
Sinus rhythm. Right bundle-branch block. Diffuse non-specific ST
segment
changes. Possible prior lateral myocardial infarction of
indeterminate age.
Compared to the previous tracing of ___ the ventricular
rate is faster.
Rate PR QRS QT/QTc P QRS T
81 ___ 94 121 66
HIP XRAY/PELVIS/ANKLE XRAY ___:
FINDINGS: There is a transverse fracture at the midcervical
level of the
right femoral neck. The fracture is minimally displaced. No
other fractures
are identified. There are mild degenerative changes of the
bilateral hips.
The sacroiliac joints and pubic symphysis are intact. There is
no fracture in
the visualized portions of the tibia and fibula. The ankle
mortise and
syndesmosis are intact. The bowel gas pattern is normal.
IMPRESSION: Transverse mildly displaced fracture through right
femoral neck.
PREOPERATIVE CXR ___
FINDINGS: In comparison to prior radiograph, there is no
significant change.
Mild diffuse interstitial abnormalities are stable. There is
underlying
emphysema. There is no consolidation, pleural effusion,
pulmonary edema, or
pneumothorax. The aorta is calcified and tortuous. The heart
size is
minimally enlarged.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Stable mild cardiomegaly.
3. Stable interstitial disease and emphysema.
POST OPERATIVE HIP XRAY ___
FINDINGS: Comparison is made to prior study of ___.
Two fluoroscopic images of the right hip from the operating room
demonstrates
interval placement of three cannulated screws and washers
fixating a fracture
involving the junction of the femoral head and neck. There is
good anatomic
alignment and no signs of hardware-related complications. The
total
fluoroscopic time was 132.6 seconds. Please refer to the
operative note for
additional details.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) 0.4-300-250
mg-mcg-mcg Oral qday
2. risedronate *NF* 150 mg Oral qmonth
Takes on the ___ of each month.
3. Warfarin 8 mg PO DAILY16
4. Vitamin D 400 UNIT PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Calcium Carbonate 600 mg PO DAILY
7. Sarna Lotion 1 Appl TP TID:PRN pruritus
8. PredniSONE 10 mg PO EVERY ___ DAY Duration: 7 Days
Should get last dose of prednisone ___
Tapered dose - DOWN
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Calcium Carbonate 500 mg PO TID
3. PredniSONE 10 mg PO EVERY ___ DAY Duration: 7 Days
Should get last dose of prednisone ___
Tapered dose - DOWN
4. Warfarin 10 mg PO DAILY16
5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
6. Docusate Sodium 100 mg PO BID
7. Morphine Sulfate ___ mg IV Q4H:PRN pain
8. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) 0.4-300-250
mg-mcg-mcg Oral qday
9. Omeprazole 40 mg PO DAILY
10. risedronate *NF* 150 mg Oral qmonth
Takes on the ___ of each month.
11. Sarna Lotion 1 Appl TP TID:PRN pruritus
12. Vitamin D 800 UNIT PO DAILY
13. traZODONE 50 mg PO HS:PRN insomnia
14. Senna 1 TAB PO DAILY
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Oxycodone SR (OxyconTIN) 10 mg PO Q12H
17. OxycoDONE (Immediate Release) 5 mg PO Q3H:PRN pain
18. Enoxaparin Sodium 60 mg SC Q12H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Hip Fracture
Secondary: Pulmonary Embolism
Ulcerative Proctitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: Right hip pain.
COMPARISONS: None.
FINDINGS: There is a transverse fracture at the midcervical level of the
right femoral neck. The fracture is minimally displaced. No other fractures
are identified. There are mild degenerative changes of the bilateral hips.
The sacroiliac joints and pubic symphysis are intact. There is no fracture in
the visualized portions of the tibia and fibula. The ankle mortise and
syndesmosis are intact. The bowel gas pattern is normal.
IMPRESSION: Transverse mildly displaced fracture through right femoral neck.
Radiology Report
INDICATION: Preoperative chest radiograph for right femur repair.
COMPARISONS: CT chest, ___. Chest radiograph, ___.
FINDINGS: In comparison to prior radiograph, there is no significant change.
Mild diffuse interstitial abnormalities are stable. There is underlying
emphysema. There is no consolidation, pleural effusion, pulmonary edema, or
pneumothorax. The aorta is calcified and tortuous. The heart size is
minimally enlarged.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Stable mild cardiomegaly.
3. Stable interstitial disease and emphysema.
Radiology Report
STUDY: Right hip intraoperative study, ___.
CLINICAL HISTORY: Patient with right hip fracture ORIF.
FINDINGS: Comparison is made to prior study of ___.
Two fluoroscopic images of the right hip from the operating room demonstrates
interval placement of three cannulated screws and washers fixating a fracture
involving the junction of the femoral head and neck. There is good anatomic
alignment and no signs of hardware-related complications. The total
fluoroscopic time was 132.6 seconds. Please refer to the operative note for
additional details.
Radiology Report
PORTABLE AP CHEST X-RAY
INDICATION: COPD, PE on Coumadin, pulmonary hypertension, shortness of
breath.
COMPARISON: Chest x-rays from ___ to ___. Chest
CTA, ___.
FINDINGS:
Lungs are clear. There is no pulmonary edema or lung consolidation. Cardiac
contour is mildly enlarged. There is no pleural effusion or pneumothorax.
CONCLUSION:
There are no acute cardiopulmonary findings.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LOWER EXTREMITY PAIN
Diagnosed with FX NECK OF FEMUR NOS-CL, UNSPECIFIED FALL
temperature: 97.2
heartrate: 56.0
resprate: 20.0
o2sat: 99.0
sbp: 142.0
dbp: 82.0
level of pain: 5
level of acuity: 3.0 | Ms. ___-
It has been a pleasure taking care of you at ___. You were
admitted to the hospital after a fall. You had a hip fracture,
and orthopedic surgery saw you and put pins in your hip to
stabalize the fracture.
As you could not take warfarin (AKA COUMADIN) prior to your
operation, you were started on a heparin drip to treat your
pulmonary embolism. After your surgery, your warfarin was
resumed, however your INR (the lab test your doctors ___ to
make sure your warfarin is working) was too low, so you were
continued on a heparin drip. You will receive an injectable
medication at rehab very similar to heparin called enoxaparin
(AKA LOVENOX). This medication will serve to treat your
pulmonary embolism while your INR is outside therepeutic range.
You will also continue your warfarin at rehab- we have increased
the dose to 10 mg a day while you were in the hospital.
Because you had an operation, we increased your prednisone
dosing to avoid low levels of cortisol (A stress hormone) around
your surgical procedure. Your taper has been extended and will
be completed on ___.
Lastly, you had a blood transfusion while you were in the
hospital as you lost blood during your operation. You mentioned
a rash on your back prior to leaving the hospital- this appears
to be a heat rash and can be treated by avoiding prolonged
periods of contact on your back and keeping the area cool and
dry. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ hx AS, pAF, COPD on nocturnal O2, PVD, AAA s/p ___ ___,
3 vessel CAD s/p PCI on plavix, CKD, sCHF (LVEF ___, TAVR
(___), DM, HTN, prostate cancer, HL who p/w hypoxia at ___'s
office on morning of admission. Pt has had increased SOB over
the last few days. Apparently he had diet indiscretions during
the ___ and had gained about 4 pounds. His O2 sats
are normally in the ___ but had dropped to the mid ___ for the
past few nights. This morning he had SOB upon waking. He sleeps
with 3L of oxygen and at ___ degrees for the few years. He had
appointment with PCP to discuss his amiodarone given concern for
symptoms he was having blue gray coloring of the skin and nose
bleeds. His PCP found him to have low oxygen saturations with
xray showing fluid overload and as such sent him to the ED.
No CP, no wheezing/ cough/ fevers. Already took his 40mg PO
lasix this morning.
In the ED intial vitals were: 98.0 62 161/66 18 88% 5L NC
Labs were notable for: proBNP: ___, Trop-T: <0.01
CXR showed: Mild to moderate pulmonary edema, worse compared to
the previous study, with small right pleural effusion.
Patient was given: Duonebs and 125mg of methylprednisolone, 20mg
IV lasix Vitals on transfer: 98.2 73 175/86 25 93% Nasal Cannula
On the floor patient looks stable and on 6L of oxygen at 93%
ROS: On review of systems, s/he denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. S/he denies recent
fevers, chills or rigors. S/he denies exertional buttock or calf
pain. All of the other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
CAD with 3 vessel disease s/p PCI of the LAD and RCA
sCHF EF 27%
Paroxysmal atrial fibrillation
3. OTHER PAST MEDICAL HISTORY:
Hypertension
Prediabetes
Coronary Artery Disease - 3 vessel disease s/p PCI in ___
Prostate Cancer
Hyperlipidemia
AAA s/p stent graft repair (___) done with a Zenith graft
COPD
CHF
CKD stage III
Social History:
___
Family History:
Grandmother died of diabetes and aunt of scleroderma. No family
history of early MI, arrhytmia or cardiomyopathy
Physical Exam:
Admission physical exam:
VS: T= 98.5 BP= 176/78 HR=81 RR= 20 O2 sat= 93% on 6L
Weight: (Dry weight 160.27Ibs) 76.9kg
GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP difficult to appreciate ~ 4cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/rubs/gallops appreciated. No
thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Significant crackles at
bases, no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: Trace edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: 2+ pedal pulses
Discharge physical exam:
VS: 98.4 129/55 (116-139/50-61) 18 94% on 3L (Other sats as
above)
Wt: 75 -> 71 kg ->74.6 kg -> 74.7kg -> 72.8kg -> 72.7kg -> 73kg
((Dry weight 160.27Ibs, 72 kg)
I/O: 8h /___
GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP difficult to appreciate but ~ 4cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/rubs/gallops appreciated. No
thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Still minor crackles at
bases, no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: 2+ pedal pulses
Pertinent Results:
Admission labs
___ 12:00PM BLOOD WBC-6.7 RBC-4.27*# Hgb-11.8*# Hct-36.6*#
MCV-86 MCH-27.6 MCHC-32.1 RDW-15.9* Plt ___
___ 12:00PM BLOOD ___ PTT-32.3 ___
___ 12:00PM BLOOD Glucose-113* UreaN-14 Creat-1.1 Na-141
K-3.7 Cl-102 HCO3-30 AnGap-13
___ 09:00PM BLOOD Calcium-9.1 Mg-2.0
___ 12:38PM BLOOD Lactate-1.6
Discharge labs
___ 07:06AM BLOOD WBC-7.5 RBC-4.03* Hgb-11.3* Hct-34.7*
MCV-86 MCH-28.0 MCHC-32.6 RDW-15.8* Plt ___
___ 07:06AM BLOOD ___ PTT-29.5 ___
___ 07:06AM BLOOD Glucose-104* UreaN-26* Creat-1.1 Na-143
K-3.5 Cl-105 HCO3-30 AnGap-12
___ 07:06AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.2
Imaging
FINDINGS:
The patient is status post median sternotomy with aortic
___ device again noted in unchanged position. Cardiac
silhouette remains unchanged, mildly enlarged. The aorta is
tortuous and diffusely calcified. Mild to
moderate pulmonary edema is somewhat worse compared to the
previous exam. Small right pleural effusion is noted. Bibasilar
atelectasis is demonstrated. No pneumothorax is identified.
Multilevel degenerative changes are seen in the thoracic spine.
IMPRESSION:
Mild to moderate pulmonary edema, worse compared to the previous
study, with small right pleural effusion.
CARDIAC ECHO ___
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity is mildly dilated. There
is moderate to severe global left ventricular hypokinesis (LVEF
= 30 %). The estimated cardiac index is depressed
(<2.0L/min/m2). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size is normal. Tricuspid annular plane
systolic excursion is normal (>2.0cm) consistent with normal
right ventricular systolic function. The ascending aorta is
mildly dilated. An aortic ___ prosthesis is present. The
aortic valve prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___ the
findings are similar (there may be increased regional
dysfunction in the inferior wall but the hypokinesis is
primarily global).
Chest xray ___
IMPRESSION:
As compared to the previous radiograph, the lung volumes have
increased. Bilateral areas of parenchymal opacities at both the
left and the right lung base have decreased in extent and
severity. No new parenchymal opacities. No pulmonary edema. No
larger pleural effusions. Known an unchanged scarring in the
left upper lobe. Normal size of the heart, status post aortic
valve replacement. Status post sternotomy. Mild elongation of
the descending aorta
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Carvedilol 12.5 mg PO BID
4. Clopidogrel 75 mg PO DAILY
5. Cyanocobalamin 500 mcg PO DAILY
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Magnesium Oxide 400 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. Amiodarone 200 mg PO DAILY
10. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN dyspnea
11. Furosemide 40 mg PO DAILY
12. Lisinopril 40 mg PO DAILY
Discharge Medications:
]
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Carvedilol 18.75 mg PO BID
RX *carvedilol 6.25 mg 3 tablet(s) by mouth Twice a day Disp
#*90 Tablet Refills:*1
4. Clopidogrel 75 mg PO DAILY
5. Cyanocobalamin 500 mcg PO DAILY
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Lisinopril 40 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. Magnesium Oxide 400 mg PO DAILY
10. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN dyspnea
11. Pantoprazole 20 mg PO Q24H
___ hour before breakfast
12. Amlodipine 10 mg PO DAILY
13. Outpatient Lab Work
Check Chem 10 (especially K+) on ___ and please fax
results to Dr ___ ___ & ___ fax 617-ICD-9
Code 428.0
14. Spironolactone 12.5 mg PO DAILY
RX *spironolactone [Aldactone] 25 mg 0.5 (One half) tablet(s) by
mouth Daily Disp #*40 Tablet Refills:*1
15. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth Daily Disp #*80 Tablet
Refills:*1
16. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K > 4.5
RX *potassium chloride [Klor-Con M20] 20 mEq 1 tablet(s) by
mouth Daily Disp #*30 Tablet Refills:*1
17. Oxygen
Ambulatory O2 sat is 86%.
Home O2 at 3L continuous; 3L during sleep.
Please provide home oxygen tank. ICD-9 code ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Acute systolic heart failure
Secondary:
Coronary artery disease
chronic obstructive pulmonary disease
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - with walker
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with shortness of breath and wheezing
TECHNIQUE: Upright AP view of the chest
COMPARISON: ___
FINDINGS:
The patient is status post median sternotomy with aortic ___ device
again noted in unchanged position. Cardiac silhouette remains unchanged,
mildly enlarged. The aorta is tortuous and diffusely calcified. Mild to
moderate pulmonary edema is somewhat worse compared to the previous exam.
Small right pleural effusion is noted. Bibasilar atelectasis is demonstrated.
No pneumothorax is identified. Multilevel degenerative changes are seen in the
thoracic spine.
IMPRESSION:
Mild to moderate pulmonary edema, worse compared to the previous study, with
small right pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with PMHx notable for congestive heart failure (EF ___,
aortic stenosis s/p TAVR (___), 3-vessel coronary artery disease (s/p PCI
of the LAD and RCA), paroxysmal afib (previously on amio), COPD on home
oxygen, AAA s/p ___ ___ admitted for shortness of breath. // Evaluate for
pulmonary edema progression given O2 requirement. Evaluate for pulmonary
edema progression given O2 requiremen
IMPRESSION:
In comparison with the study of ___, the core valve is again seen with
continued elevation of pulmonary venous pressure. Bibasilar opacification is
consistent with atelectasis. In the appropriate clinical setting, coalescent
areas at the left and possibly right base could raise the possibility of
developing aspiration or infectious pneumonia.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with PMHx notable for congestive heart failure (EF ___,
aortic stenosis s/p TAVR (___), 3-vessel coronary artery disease (s/p PCI
of the LAD and RCA), paroxysmal afib (previously on amio), COPD on home
oxygen, AAA s/p ___ ___ admitted for shortness of breath. // ? lung
infiltrate
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, the lung volumes have increased.
Bilateral areas of parenchymal opacities at both the left and the right lung
base have decreased in extent and severity. No new parenchymal opacities. No
pulmonary edema. No larger pleural effusions. Known an unchanged scarring in
the left upper lobe. Normal size of the heart, status post aortic valve
replacement. Status post sternotomy. Mild elongation of the descending aorta.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with RESPIRATORY ABNORM NEC
temperature: 98.0
heartrate: 62.0
resprate: 18.0
o2sat: 88.0
sbp: 161.0
dbp: 66.0
level of pain: nan
level of acuity: 2.0 | Dear Mr. ___,
It was a pleasure caring for you at ___. You came to the
hospital because you were having shortness of breath. We found
this was from a heart failure exacerbation likely from dietary
indiscretion. We treated you with intravenous diuretics and your
symptoms improved. Your amiodarone was stopped due to side
effects.
We changed your lasix from 40mg daily to torsemide 40mg daily.
(you will need to f/u with your doctor and have laboratory
checked on ___. We also increased your
carvedilol from 12.5mg to 18.75mg due to hypertension. We also
added daily potassium to your medication regimen and a new
medication called spironolactone which will help your heart and
prevent potassium loss as well.
You should continue to take all your medications and adhere to a
strict low sodium (2g/day) diet (eat bananas and tomatoes for
their potassium content) and restrict your fluids to less than 2
liters per day.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
It was a pleasure being part of your care.
Your ___ Medicine Team |
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