Age: 64.0
Sex: M
Vaccine: COVID19
Symptoms: Magnetic resonance imaging spinal abnormal, Moisture-associated skin damage, Myelitis transverse, Osteoarthritis, Pain
Clinical narrative: Date of Admission: 12/16/2023   Date of Discharge: 1/3/2024   Issues to be Addressed at Follow-up: Pain HTN   Pending Study Results at Discharge:  Unresulted Lab Orders    No orders found from 11/29/2023 to 12/30/2023.       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) TRANSVERSE MYELITIS   ? PARAPLEGIA   ? RETROPERITONEAL HEMATOMA   ? ANEMIA   ? PREDIABETES       Diet controlled Previously on metformin - stopped mid-2023   ? DM 2 W HYPERLIPIDEMIA       Reports not currently using Metformin    Lab Results Component Value Date   Hgb A1c % 5.6 08/22/2023       ? IMMUNOCOMPROMISED DUE TO MEDICATION   ? RHEUMATOID ARTHRITIS   ? BPH W LOWER URINARY TRACT SYMPTOMS   ? HTN (HYPERTENSION)       Taking HCTZ 25 mg daily    BP Readings from Last 3 Encounters: 10/19/23 165/100 04/18/23 115/70 03/27/23 125/78       ? HX OF LUMBOSACRAL SPINE SURGERY   ? OBSTRUCTIVE SLEEP APNEA       9/11/2016: SEVERE severity OSA on Watch-PAT study with pAHI=31.2, low SpO2=83% (200lbs)       Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  Home with Home Health   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   HPI (per Dr.): Patient is a 66 Y right handed male with PMH of prediabetes, BPH, OSA, HTN, rheumatoid arthritis, lumbar disc herniation with history of lumbar laminectomy and diskectomy in 2016, hx of C5-6 laminectomy and fusion in 1991 and chronic back pain who presented to facility on 11/23/2023 with acute on chronic weakness with numbness from waist down. He was transferred to another facility on 11/24/2023 for further management. MRI c spine with severe cord compression and mild T2 signal change in cord with mod to severe canal stenosis C7-T1 and T spine with diffuse abnormal signaling throughout thoracic cord concerning for transverse myelitis. He was treated with 5 days of 1gm of Solu-Medrol that completed on 11/28/2023. Patient continued to complain of pain, paresthesias with ongoing weakness, so neurology recommended a slow taper of prednisone to complete on12/11/2023.  He was discharged to acute inpatient  rehabilitation at Rehab Hospital on 12/2/2023.   On 12/11/2023, patient presented to facility from acute rehab with acute onset of low back pain with loss of sensation at his upper abdominal level with paresis of his bilateral lower extremities. Workup revealed a significant drop in hemoglobin and MRI T spine demonstrated severe DJD, severe foraminal stenosis with old lesions suggestive of demyelinating process but no new lesion. MRI L spine signaling concerning for hematoma in the area of the right iliacus. Patient did not present with bowel or bladder incontinence or urinary retention. Etiology of his acute symptoms per neurology were possibly related to his spontaneous hematoma. He did not require any intervention per IR as his hematoma is expected to resolve overtime. Per neurology, patient was restarted back on prednisone taper with plan for 30 mg for one week, 20 mg for one week, 10 mg for one week and 5 mg for one week with follow up with neurology to adjust the dosing of steroids further. PT, OT and PM&R (Dr.) consulted and recommended patient to return to acute inpatient rehabilitation program to upgrade his function prior to discharge home into the community.    Hospital Course and Significant Findings: Neuro: He has history of C5-C6 laminectomy/fusion 1991 and L2-L3 laminectomy/L5-S1 microdiscectomy/left L2-L3 microdiscectomy 6/7/2016.  He developed T11 AIS D incomplete spinal cord injury on 11/24/2023 secondary to transverse myelitis.  Per Dr. (neurology), patient requires treatment with steroid taper (prednisone 30 mg daily 12/12-12/18, 20 mg daily 12/19-12/25, 10 mg daily 12/26-1/1/2024, 5 mg daily 1/2/2024-1/8/2024, then stop).  He will follow up with neurology after discharge   Rheum: He has history of RA.  This was managed with methotrexate and folic acid   Heme: CT 12/12/2023 showed right retroperitoneal hematoma.  No acute intervention indicated per review by Dr. (interventional radiologist) and Dr. (general surgery).  Hematocrit remained stable during rehabilitation stay.     CV: He has history of HTN, but blood pressure remained stable throughout rehabilitation stay.      Pulm: He has history of OSA, but patient is noncompliant with CPAP at home   Endo: He has history of prediabetes.  Insulin sliding scale was provided while inpatient to manage steroid-induced hyperglycemia.     ID: He had recently developed COVID 11/28/2023.  He had mild leukocytosis likely related to steroids.     FEN/GI: He tolerated regular consistency/thin liquid diet.  He received famotidine for GI prophylaxis while on steroids   Bowel: He received docusate to prevent constipation.  He also had senna prn and bisacodyl prn available.   Bladder: He has history of BPH.  He is able to have voluntary voids with PVR 0-123   Sleep/Mood/Psych:  Per patient request, avoid melatonin as this has paradoxical effect on patient (making him more awake).  Neuropsychology provided assistance during stay.  He had trazodone available prn for mood.     Pain: Pain was managed with scheduled gabapentin.  He also had acetaminophen prn and oxycodone-acetaminophen prn available.   Skin: He developed moisture associated skin damage at right inner buttock 12/27/2023.  Per wound care specialist, this was managed with Triad applied to right inner buttock.  He was turned q2h.  SCI pressure ulcer prevention protocol was implemented.     DVT Proph: Ultrasound of lower extremities on 12/14/2023 was negative for DVT.  He received heparin for DVT prophylaxis while inpatient.  He was switched to enoxaparin at discharge to improve ease of administration.  He will need to continue enoxaparin for 15 days after discharge to complete 8 week course of treatment (end date 1/18/2024).     Primary Procedures:  None   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  Transverse myelitis   Complications: none   Consults:  INPATIENT NEUROPSYCHOLOGY CONSULT Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code   I consulted the database on 12/29/2023         Note Details  Author (M.D.) File Time 1/3/2024  9:28 AM Author Type Physician Status Signed Last Editor  (M.D.) Specialty Physical Med/Rehabilitation  Admit Date 12/16/2023  Admission (Discharged) on 12/16/2023  Admission (Discharged) on 12/16/2023   Revision History   Detailed Report  Note shared with patient Additional Orders and Documentation   Results    Meds    Orders    Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Linked Episodes  IP Rehab episode from 12/16/23 From 12/16/2023 to 1/7/2024  Hospital Problem List   HTN (HYPERTENSION)  RHEUMATOID ARTHRITIS  DM 2 W HYPERLIPIDEMIA  IMMUNOCOMPROMISED DUE TO MEDICATION  TRANSVERSE MYELITIS  OBSTRUCTIVE SLEEP APNEA  HX OF LUMBOSACRAL SPINE SURGERY  BPH W LOWER URINARY TRACT SYMPTOMS  PREDIABETES  ANEMIA  PARAPLEGIA  RETROPERITONEAL HEMATOMA Care Timeline  12/16   Admitted 1425 01/03   Discharged 1132  Discharge   Home with Home Health   Discharge Instructions (AVS) (Printed 1/3/2024) Medication List at Discharge   acetaminophen 650 mg Oral EVERY 4 HOURS AS NEEDED  docusate sodium 100 mg Oral 2 TIMES A DAY  enoxaparin sodium 40 mg Subcutaneous DAILY, Stop after 15 days  famotidine 20 mg Oral 2 TIMES A DAY BEFORE MEALS, For stomach protection while taking steroids  folic acid 1 mg Oral DAILY  gabapentin 300 mg Take 2 capsules by mouth in the morning and afternoon and 3 capsules by mouth at bedtime  methotrexate sodium 20 mg Oral EVERY 7 DAYS, For rheumatoid arthritis  oxycodone HCl/acetaminophen 5-325 mg 2 tablets Oral EVERY 4 HOURS AS NEEDED  prednisone 5 mg Oral DAILY, for 5 days, then stop