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10000032-DS-22 | 10,000,032 | 22,841,357 | DS | 22 | 2180-06-27 00:00:00 | 2180-07-01 10:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending: ___.
Chief Complaint:
abdominal fullness and discomfort
Major Surgical or Invasive Procedure:
___ diagnostic paracentesis
___ therapeutic paracentesis
History of Present Illness:
___ with HIV on HAART, COPD, HCV cirrhosis complicated by
ascites and HE admitted with abdominal distention and pain. She
was admitted to ___ for the same symptoms
recently and had 3L fluid removed (no SBP) three days ago and
felt better. Since discharge, her abdomen has become
increasingly distended with pain. This feels similar to prior
episodes of ascites.
Her diuretics were recently decreased on ___ due to worsening
hyponatremia 128 and hyperkalemia 5.1. Patient states she has
been compliant with her HIV and diuretic medications but never
filled out the lactulose prescription. She states she has had
___ BMs daily at home. She has had some visual hallucinations
and forgetfulness. Her appetite has been poor.
In the ED, initial vitals were 98.9 88 116/88 18 97% RA. CBC
near baseline, INR 1.4, Na 125, Cr 0.6. AST and ALT mildly above
baseline 182 and 126 and albumin 2.8. Diagnostic para with 225
WBC, 7% PMN, total protein 0.3. UA with few bact, 6 WBC, mod
leuk, neg nitr, but contaminated with 6 epi. CXR clear. RUQ US
with no PV thrombus, moderate ascites. She was given ondansetron
4mg IV and morphine 2.5mg IV x1 in the ED.
On the floor, she is feeling improved but still has abdominal
distention and discomfort.
ROS: +Abdominal distention and pain. No black/bloody stools. No
___ pain or swelling. No fevers or chills. Denies chest pain,
nausea, vomiting. No dysuria or frequency.
Past Medical History:
1. HCV Cirrhosis
2. No history of abnormal Pap smears.
3. She had calcification in her breast, which was removed
previously and per patient not, it was benign.
4. For HIV disease, she is being followed by Dr. ___ Dr.
___.
5. COPD
6. Past history of smoking.
7. She also had a skin lesion, which was biopsied and showed
skin cancer per patient report and is scheduled for a complete
removal of the skin lesion in ___ of this year.
8. She also had another lesion in her forehead with purple
discoloration. It was biopsied to exclude the possibility of
___'s sarcoma, the results is pending.
9. A 15 mm hypoechoic lesion on her ultrasound on ___
and is being monitored by an MRI.
10. History of dysplasia of anus in ___.
11. Bipolar affective disorder, currently manic, mild, and PTSD.
12. History of cocaine and heroin use.
Social History:
___
Family History:
She a total of five siblings, but she is not talking to most of
them. She only has one brother that she is in touch with and
lives in ___. She is not aware of any known GI or liver
disease in her family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T98.1 105/57 79 20 97RA 44.6kg
GENERAL: Thin chronically ill appearing woman in no acute
distress
HEENT: Sclera anicteric, MMM, no oral lesions
HEART: RRR, normal S1 S2, no murmurs
LUNGS: Clear, no wheezes, rales, or rhonchi
ABD: Significant distention with visible veins, bulging flanks,
nontender to palpation, tympanitic on percussion, normal bowel
sounds
EXT: no ___ edema, 2+ DP and ___ pulses
NEURO: alert and oriented, not confused, no asterixis
DISCHARGE PE:
VS: T 98.4 BP 95/55 (SBP ___ HR 80 RR 18 O2 95RA
I/O 240/150 this am
GENERAL: Thin chronically ill appearing woman in no acute
distress
HEENT: Sclera anicteric, MMM, no oral lesions
HEART: RRR, normal S1 S2, no murmurs
LUNGS: Clear, no wheezes, rales, or rhonchi
ABD: Significant distention with visible veins, bulging flanks,
nontender to palpation, tympanitic on percussion, normal bowel
sounds
EXT: no ___ edema, 2+ DP and ___ pulses
NEURO: alert and oriented, not confused, no asterixis
Pertinent Results:
LABS ON ADMISSION:
___ 04:10PM BLOOD ___
___ Plt ___
___ 04:10PM BLOOD ___
___
___ 04:10PM BLOOD ___
___
___ 04:10PM BLOOD ___
___
___ 04:10PM BLOOD ___
___ 04:39PM BLOOD ___
LABS ON DISCHARGE:
___ 05:10AM BLOOD ___
___ Plt ___
___ 05:10AM BLOOD ___ ___
___ 05:10AM BLOOD ___
___
___ 05:10AM BLOOD ___
___
___ 05:10AM BLOOD ___
MICRO:
___ 10:39 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 7:00 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ 7:00 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Diagnositc Para:
___ 07:00PM ASCITES ___
___
___ 07:00PM ASCITES ___
IMAGING:
___ CXR- No acute cardiopulmonary abnormality.
___ RUQ US-
1. Extremely coarse and nodular liver echotexture consistent
with a history of cirrhosis.
2. Moderate ascites.
3. Patent portal vein.
Brief Hospital Course:
___ with HIV on HAART, HCV cirrhosis with ascites and HE, h/o
IVDU, COPD, bipolar disorder presents with abdominal discomfort
due to ___ ascites.
# ASCITES. Now diuretic refractory given last tap was three days
ago with 3L removed and she has already built up moderate
ascites. Infectious workup negative, with CXR clear, UA
contaminated but not grossly positive so will f/u culture,
diagnostic para with only 225 WBC, RUQ US with no PV thrombus.
Compliant with diuretics but not following low sodium diet or
fluid restriction. Dr. ___ discussed possible TIPS in
the office but due to lung disease, that was on hold pending
further cardiac evaluation. Diuretics were recently decreased
due to hyponatremia and hyperkalemia. Held spironolactone for
now due to K 5.2 and increased lasix 20 -> 40. No evidence of
severe hyponatremia (Na<120) or renal failure Cr>2.0 to stop
diuretics at present. Diagnostic paracentesis negative for
infection. Ascitic total protein 0.3 so warrants SBP prophylaxis
(<1.0) and fortunately already on Bactrim for PCP prophylaxis
which would be appropriate for SBP ppx also. Patient did admit
to eating pizza and some ___ food prior to
admission. She had therapeutic paracentesis with 4.3L removed
and received 37.5G albumin IV post procedure. She felt much
better with resolution of abdominal discomfort. Patient is
scheduled for repeat paracentesis as outpatient on ___.
# HEPATIC ENCEPHALOPATHY. History of HE from Hep C cirrhosis.
Now with mild encephalopathy (hallucinations and forgetfulness)
due to medication noncompliance, but not acutely encephalopathic
and without asterixis on exam. Infectious workup negative thus
far. Continue lactulose 30mL TID and titrate to 3 BMs daily and
continue rifaximin 550mg BID.
# HYPONATREMIA. Na 125 on admission, 128 four days ago, and 135
one month ago. Likely due to third spacing from worsening
ascites and fluid overload. 1.5L fluid restriction, low salt
diet. S/p therapeutic paracentesis with albumin replacement.
# CIRRHOSIS, HEPATITIS C. MELD score of 10 and Child's ___
class B on this admission. Now decompensated due to ascites.
Hepatitis C genotype IIIB. Dr. ___ starting
___ and ___ with patient in clinic and the
insurance process was started by her office. No history of EGD,
needs this as outpatient for varices screening.
# NUTRITION. Unclear if truly compliant with low salt diet. Poor
oral intake. Low albumin 2.8 on admission. Met with nutrition.
# COAGULOPATHY. INR 1.4 four days ago. No evidence of active
bleeding. Very mild thrombocytopenia with plts 143.
# HIV. Most recent CD4 173. On HAART. No established ID
provider. Continue Truvada and Isentress, Bactrim DS daily for
PCP ___. Needs outpatient ID appointment
# COPD. Stable. States she is on intermittent home O2 for
comfort at night and with abdominal distentiom. Continued home
COPD meds and home O2 as needed
**Transitional Issues**
- Discontinued spironolactone ___ elevated potassium
- Increased furosemide to 40mg daily
- Please recheck electrolytes at next visit
- Had paracentesis ___ with 4.3 L removed, received 37.5G
albumin
- Needs outpatient ID provider
- ___ needs more frequent paracentesis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, SOB
2. ___ (Truvada) 1 TAB PO DAILY
3. Furosemide 20 mg PO DAILY
4. Raltegravir 400 mg PO BID
5. Spironolactone 50 mg PO DAILY
6. Acetaminophen 500 mg PO Q6H:PRN pain,fever
7. Tiotropium Bromide 1 CAP IH DAILY
8. Rifaximin 550 mg PO BID
9. Calcium Carbonate 1250 mg PO BID
10. Lactulose 15 mL PO TID
11. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain,fever
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, SOB
3. Calcium Carbonate 1250 mg PO BID
4. ___ (Truvada) 1 TAB PO DAILY
5. Furosemide 40 mg PO DAILY
6. Lactulose 15 mL PO TID
7. Raltegravir 400 mg PO BID
8. Rifaximin 550 mg PO BID
9. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
10. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: diuretic refractory ascites
Secondary: HCV cirrhosis, HIV, hyponatremia, COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure to take care of you at ___
___. You were admitted with abdominal fullness and
pain from your ascites. You had a diagnostic and therapeutic
paracentesis with 4.3 L removed. Your spironolactone was
discontinued because your potassium was high. Your lasix was
increased to 40mg daily. You are scheduled for another
paracentesis on ___ prior to your other appointments that day.
Please call tomorrow to find out the time of the paracentesis.
Please continue to follow a low sodium diet and fluid
restriction. You should call your liver doctor or return to the
emergency room if you have abdominal pain, fever, chills,
confusion, or other concerning symptoms.
Sincerely,
Your ___ medical team
Followup Instructions:
___
|
10000117-DS-21 | 10,000,117 | 22,927,623 | DS | 21 | 2181-11-15 00:00:00 | 2181-11-15 15:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
omeprazole
Attending: ___.
Chief Complaint:
dysphagia
Major Surgical or Invasive Procedure:
Upper endoscopy ___
History of Present Illness:
___ w/ anxiety and several years of dysphagia who p/w worsened
foreign body sensation.
She describes feeling as though food gets stuck in her neck when
she eats. She put herself on a pureed diet to address this over
the last 10 days. When she has food stuck in the throat, she
almost feels as though she cannot breath, but she denies trouble
breathing at any other time. She does not have any history of
food allergies or skin rashes.
In the ED, initial vitals: 97.6 81 148/83 16 100% RA
Imaging showed: CXR showed a prominent esophagus
Consults: GI was consulted.
Pt underwent EGD which showed a normal appearing esophagus.
Biopsies were taken.
Currently, she endorses anxiety about eating. She would like to
try eating here prior to leaving the hospital.
Past Medical History:
- GERD
- Hypercholesterolemia
- Kidney stones
- Mitral valve prolapse
- Uterine fibroids
- Osteoporosis
- Migraine headaches
Social History:
___
Family History:
+ HTN - father
+ Dementia - father
Physical Exam:
=================
ADMISSION/DISCHARGE EXAM
=================
VS: 97.9 PO 109 / 71 70 16 97 ra
GEN: Thin anxious woman, lying in bed, no acute distress
HEENT: Moist MM, anicteric sclerae, NCAT, PERRL, EOMI
NECK: Supple without LAD, no JVD
PULM: CTABL no w/c/r
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended, +BS, no HSM
EXTREM: Warm, well-perfused, no ___ edema
NEURO: CN II-XII grossly intact, motor function grossly normal,
sensation grossly intact
Pertinent Results:
=============
ADMISSION LABS
=============
___ 08:27AM BLOOD WBC-5.0 RBC-4.82 Hgb-14.9 Hct-44.4 MCV-92
MCH-30.9 MCHC-33.6 RDW-12.1 RDWSD-41.3 Plt ___
___ 08:27AM BLOOD ___ PTT-28.6 ___
___ 08:27AM BLOOD Glucose-85 UreaN-8 Creat-0.9 Na-142 K-3.6
Cl-104 HCO3-22 AnGap-20
___ 08:27AM BLOOD ALT-11 AST-16 LD(LDH)-154 AlkPhos-63
TotBili-1.0
___ 08:27AM BLOOD Albumin-4.8
=============
IMAGING
=============
CXR ___:
IMPRESSION:
Prominent esophagus on lateral view, without air-fluid level.
Given the patient's history and radiographic appearance, barium
swallow is indicated either now or electively.
NECK X-ray ___:
IMPRESSION:
Within the limitation of plain radiography, no evidence of
prevertebral soft tissue swelling or soft tissue mass in the
neck.
EGD: ___
Impression: Hiatal hernia
Angioectasia in the stomach
Angioectasia in the duodenum
(biopsy, biopsy)
Otherwise normal EGD to third part of the duodenum
Recommendations: - no obvious anatomic cause for the patient's
symptoms
- follow-up biopsy results to rule out eosinophilic esophagitis
- follow-up with Dr. ___ if biopsies show eosinophilic
esophagitis
Brief Hospital Course:
Ms. ___ is a ___ with history of GERD who presents with
subacute worsening of dysphagia and foreign body sensation. This
had worsened to the point where she placed herself on a pureed
diet for the last 10 days. She underwent CXR which showed a
prominent esophagus but was otherwise normal. She was evaluated
by Gastroenterology and underwent an upper endoscopy on ___.
This showed a normal appearing esophagus. Biopsies were taken.
TRANSITIONAL ISSUES:
-f/u biopsies from EGD
-if results show eosinophilic esophagitis, follow-up with Dr. ___.
___ for management
-pt should undergo barium swallow as an outpatient for further
workup of her dysphagia
-f/u with ENT as planned
#Code: Full (presumed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO BID
Discharge Medications:
1. Omeprazole 20 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
-dysphagia and foreign body sensation
SECONDARY DIAGNOSIS:
-GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized at ___.
You came in due to difficulty swallowing. You had an endoscopy
to look for any abnormalities in the esophagus. Thankfully, this
was normal. They took biopsies, and you will be called with the
results. You should have a test called a barium swallow as an
outpatient.
We wish you all the best!
-Your ___ Team
Followup Instructions:
___
|
10000935-DS-19 | 10,000,935 | 21,738,619 | DS | 19 | 2187-07-12 00:00:00 | 2187-07-12 14:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Codeine / Bactrim
Attending: ___
Chief Complaint:
nausea, vomiting, cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ female, with past medical history significant for
depression, hyperlipidemia, Hysterectomy, B12 deficiency, back
pain, carcinoid, cervical DJD, depression, hyperlipidemia,
osteoarthritis, and history of Exploratory laparotomy, lysis of
adhesions, and small bowel resection with enteroenterostomy for
a high grade SBO ___ who presents with nausea, vomiting,
weakness x 2 weeks. She has been uable to tolerate PO liquids,
and solids. Had similar presentation ___ for high grade SBO.
Denies passing flatus today. However reports having last normal
bowel movement this AM, without hematochezia, melena. Also
reporting subjective fever (100.0), non productive cough. Denies
HA, myalgias. Takes NSAIDS sparingly. Denies alcohol use. Denies
sick contacs/ travel or recent consumption of raw foods. Has
never had a colonoscopy.
.
In ED VS were 97.8 120 121/77 20 98% RA
Labs were remarkable for lactate 2.8, alk phos 293, HCT 33, WBC
13.9
Imaging: CT abdomen showed mult masses in the liver, consistent
with malignancy. CXR also showed multiple nodules
EKG: sinus, 112, NA, NI, TWI in III, but largely unchanged from
prior
Interventions: zofran, tylenol, 2L NS, GI was contacted and they
are planning on upper / lower endoscopy for cancer work-up.
.
Vitals on transfer were 99.2 113 119/47 26 98%
Past Medical History:
PMH:
# high grade SBO ___ s/p exploratory laparotomy, lysis of
adhesions, and small bowel resection with enteroenterostomy
# carcinoid
# hyperlipidemia
# vitamin B12 deficiency
# cervical DJD
# osteoarthritis
PSH:
s/p R lung resection in ___ at ___
s/p hysterectomy in ___
s/p R arm surgery
Social History:
___
Family History:
non contributory
Physical Exam:
On admission
VS: 98.9 137/95 117 20 100 RA
GENERAL: AOx3, NAD
HEENT: MMM. no JVD. neck supple.
HEART: Regular tachycardic, S1/S2 heard. no
murmurs/gallops/rubs.
LUNGS: CTAB, non labored
ABDOMEN: soft, tender to palpation in epigastrium.
EXT: wwp, no edema. DPs, PTs 2+.
SKIN: dry, no rash
NEURO/PSYCH: CNs II-XII intact. strength and sensation in U/L
extremities grossly intact. gait not assessed.
On Discharge:
VS: 98.7 118/78 97 20 99RA
GENERAL: Patient is sitting in a chair, appears comfortable,
A+Ox3, cooperative.
HEENT: EOMI, PERRLA, No Pallor or Jaundice, MMM, no JVD, neck
supple.
HEART: RRR, no m/r/g.
LUNGS: CTAB
ABDOMEN: obese, soft, mild tenderness on mid +right epigastrium
w/o peritoneal signs, no shifting dullness, difficult to
appreciate organomegaly.
EXT: wwp, no edema, no signs of DVT
SKIN: no rash, normal turgor
NEURO: no gross deficits
PSYCH: appropriate affect, no preceptual disturbances, no SI,
normal judgment.
Pertinent Results:
___ 03:14PM ___
___ 12:50PM URINE HOURS-RANDOM
___ 12:50PM URINE UHOLD-HOLD
___ 12:50PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-TR
___ 12:50PM URINE RBC-2 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-2
___ 09:54AM LACTATE-2.8*
___ 09:45AM GLUCOSE-96 UREA N-7 CREAT-0.5 SODIUM-138
POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-27 ANION GAP-15
___ 09:45AM estGFR-Using this
___ 09:45AM ALT(SGPT)-17 AST(SGOT)-46* ALK PHOS-293* TOT
BILI-0.5
___ 09:45AM LIPASE-14
___ 09:45AM ALBUMIN-3.0*
___ 09:45AM ___ AFP-1.7
___ 09:45AM WBC-13.9* RBC-3.94* HGB-9.8* HCT-33.0*
MCV-84# MCH-25.0*# MCHC-29.9* RDW-16.1*
___ 09:45AM NEUTS-75.2* LYMPHS-17.9* MONOS-5.9 EOS-0.7
BASOS-0.3
___ 09:45AM PLT COUNT-657*#
CT abdomen/pelvis
1. Innumerable hepatic and pulmonary metastases. No obvious
primary
malignancy is identified on this study.
2. No evidence of small bowel obstruction, ischemic colitis,
fluid collection,
or perforation.
CXR:
New nodular opacities within both upper lobes, left greater than
right.
Findings are compatible with metastases, as was noted in the
lung bases on the
subsequent CT of the abdomen and pelvis performed later the same
day.
Brief Hospital Course:
___ Female with PMH significant for depression,
hyperlipidemia, Hysterectomy, B12 deficiency, OA, carcinoid,
cervical DJD, depression, SBO who presented with nausea,
vomiting, weakness x 2 weeks and was found to have multiple
liver and lung masses per CT consistent with metastatic cancer
of unknown primary.
Patient was treated with IV fluids overnight for dehydration.
She refused to stay in the hospital for any further work-up or
treatment and stated she would rather go home to to think and
see to her affairs over the weekend and consider pursuing
further work-up as an outpatient. She tolerated oral fluids well
w/o vomiting. She remained hemodynamically stable and afebrile
throughout her stay.
Of note patient has psychiatric history of depressive symptoms
and isolation tendencies. She denied any SI/SA or any risk to
herself. She has little social supports but does have a good
relationship with her driver and friend who came in and was
updated by the medical team on the morning of discharge and will
be taking her home. She sees a mental health provider at ___
once a month and has a good relationship with her primary care
physician. Patient was dischaerged home at her request. Home
medications were continued to which we added some symptomatic
treatment for her cough with benzonatate and Guaifenesin. We
held off on anti-emetics for now as she did not want to stay
inhouse to make sure these would be well tolerated (would need
to monitor for drug interactions given multiple QTc prolonging
and serotonergic medications on her home meds). She was
instructed to maintain good hydration and try a soft diet at
home if she can not tolerate regular diet. The patient met with
SW who provided her with resources for community councelling.
Outpatient appointments with oncology, GI and her PCP were set
up and her PCP and mental health provider were updated. Her PCP
___ also ___ with her later today by telephone.
Medications on Admission:
The Preadmission Medication list is accurate and complete
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing/SOB
2. BuPROPion 150 mg PO DAILY
3. Gabapentin 300 mg PO TID
4. Ibuprofen 800 mg PO Q8H:PRN pain
5. Sertraline 200 mg PO DAILY
6. Simvastatin 40 mg PO DAILY
7. Tizanidine 4 mg PO BID:PRN muscle spasms/pain
8. traZODONE 100 mg PO HS:PRN sleep
9. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
2. BuPROPion 150 mg PO DAILY
3. Gabapentin 300 mg PO TID
4. Sertraline 200 mg PO DAILY
5. Simvastatin 40 mg PO DAILY
6. Tizanidine 4 mg PO BID:PRN muscle spasms/pain
7. traZODONE 100 mg PO HS:PRN sleep
8. Ibuprofen 800 mg PO Q8H:PRN pain
9. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID
10. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth TID: PRN cough Disp
#*60 Capsule Refills:*0
11. Guaifenesin ___ mL PO Q6H:PRN cough
RX *guaifenesin 100 mg/5 mL ___ ml by mouth Q6H:PRN cough Disp
#*1 Bottle Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Liver and Lung Mets of unkown primary
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were seen in the ED for ongoing cough, nausea and vomiting
and had imaging studies which unfortunately showed spots in your
liver and lungs which are likely due to wide-spread cancer. ___
were admitted for further work-up and treatment of your
symptoms. ___ chose to not have any more work-up in the hospital
and wanted to be discharged home as soon as possible.
Please make sure ___ keep well hydrated by taking water sips
throughout the day. I also prescribed some symptomatic treatment
for your nausea and cough.
I updated your PCP and ___ and have set up ___
appointments as below.
Followup Instructions:
___
|
10000935-DS-21 | 10,000,935 | 25,849,114 | DS | 21 | 2187-10-26 00:00:00 | 2187-10-27 15:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Codeine / Bactrim
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Percutaneous liver biopsy
History of Present Illness:
Ms. ___ is a ___ with metastatic cancer of unknown primary
(known lesions in lungs and liver) presenting with shortness of
breath. She initially presented to ___ in ___ with abdominal
pain and failure to thrive. Evaluation at that time included an
abdominal CT scan that showed multiple lung and liver
metastases. She has yet to undergo definite diagnosis with
biopsy, and per recent oncology documentation seems disengaged
with care.
She was reportedly in her usual state of health until the
evening prior to admission, when she developed acute on chronic
shortness of breath while at rest. She reported midsternal chest
ache associated with this shortness of breath. Pain is
exacerbated by direct pressure; nothing seems to alleviate pain.
She denied any pleuritic or exertional component to the chest
pain or shortness of breath. She feels that symptoms are
secondary to her "cancer" and "feels as if the cancer has
spread". She reports stable, chronic nonproductive cough, which
has been present over the preceding months.
She was seen recently in the ED for evaluation of left greater
than right lower extremity edema with lower extremity venous
ultrasounds negative, without change in edema since since that
visit. She denies associated fever, chills, sweats, PND,
orthopnea, or positional component to pain.
In the ED, initial vital signs were: 98.0 116 100/49 24 99% RA.
Labs notable for leukocytosis to 17.9, hematocrit of 32, and
lactate of 2.8. Urinalysis was positive, but with 19 epithelial
cells. CTA was negative for central pulmonary embolus, focal
consolidation, or pleural effusion, though did reveal
innumerable pulmonary nodules, as well as enlarged liver with
stable metastases. EKG was interpreted as sinus tachycardia and
was overall consistent with prior. Ceftriaxone/azithromycin were
initiated for possible pneumonia. Vital signs on transfer were
as follows: 97.9 107 100/60 22 100% RA. On arrival to the floor,
she reports that shortness of breath has improved and that she
is chest pain free.
Past Medical History:
Per OMR:
# metastatic cancer of unknown primary
# high grade SBO ___ s/p exploratory laparotomy, lysis of
adhesions, and small bowel resection with enteroenterostomy
# carcinoid
# hyperlipidemia
# vitamin B12 deficiency
# cervical DJD
# osteoarthritis
s/p R lung resection in ___ at ___
s/p hysterectomy in ___
s/p R arm surgery
Social History:
___
Family History:
Per OMR:
Mother - Died of pancreatic cancer at age ___.
Father - Died of ___ disease at age ___.
Physical Exam:
On admission:
VS: 97.9 114/71 105 sinus 18 95%2L
GENERAL: non-toxic appearing, speaking in full sentences
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, no LAD, no JVD
CHEST: mild reproducible pain on palp of midsternum; no palpable
mass
LUNGS: poor aeration but relatively CTA bilat, no r/rh/wh, resp
unlabored, no accessory muscle use
HEART: clear and audible heart sounds, tachycardiac but regular
rhythm, sofy SEM, nl S1-S2
ABDOMEN: normal bowel sounds, soft, mild tenderness to palp
throughout and more pronounced in the RUQ, non-distended, no
rebound or guarding, palpable liver edge
EXTREMITIES: left > right 1+ pitting edema to mid shin, 2+
pulses radial and dp
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact
At discharge:
VS - Tc 99.7, 116/59, 131, 18, 99% RA
GENERAL: obese, NAD, lying in bed comfortably, flat affect and
poor eye contact
HEENT: NCAT, EOMI, mild scleral icterus, pink conjunctiva, MMM,
poor dentition, mild palor of conjunctiva
NECK: supple, no LAD
CARDIAC: tachycardic but regular, S1/S2, no m/r/g
LUNG: CTAB in anterior fields, decreased breath sounds at right
base, exam limited secondary to body habitus and mobility, no
w/r/r, no accessory muscle use
ABDOMEN: obese, ND, +BS, no rebound/guarding, localized area of
firmness in mid-upper abdomen and tender to palpation over this
area
EXTREMITIES: WWP, 2+ DP pulses bilaterally, 1+ pitting edema to
torso bilateraly
NEURO: no asterixis, moving all four extremities, minimal
movement ___ to gravity but distal muscles 4+/5, good hand
grip strength today
Pertinent Results:
On admission:
___ 12:50PM BLOOD WBC-17.9* RBC-3.69* Hgb-9.5* Hct-32.1*
MCV-87 MCH-25.8* MCHC-29.7* RDW-19.1* Plt ___
___ 12:50PM BLOOD Neuts-82.8* Lymphs-11.7* Monos-4.4
Eos-0.7 Baso-0.3
___ 12:50PM BLOOD ___ PTT-31.2 ___
___ 12:50PM BLOOD Glucose-97 UreaN-12 Creat-0.6 Na-140
K-2.7* Cl-92* HCO3-31 AnGap-20
___ 12:50PM BLOOD ALT-17 AST-73* LD(___)-586* CK(CPK)-218*
AlkPhos-340* TotBili-2.6* DirBili-1.8* IndBili-0.8
___ 12:50PM BLOOD CK-MB-1 cTropnT-<0.01
___ 12:50PM BLOOD Albumin-2.5* Mg-2.2
___ 12:50PM BLOOD Hapto-307*
___ 05:12PM BLOOD Lactate-2.8*
___ 06:00PM URINE Color-YELLOW Appear-Cloudy Sp ___
___ 06:00PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-SM Urobiln-8* pH-6.0 Leuks-MOD
___ 06:00PM URINE RBC-0 WBC-66* Bacteri-FEW Yeast-NONE
Epi-14
___ 06:00PM URINE CastHy-6*
At discharge:
___ 08:30AM BLOOD WBC-16.1* RBC-3.06* Hgb-8.3* Hct-29.2*
MCV-95 MCH-27.1 MCHC-28.5* RDW-22.5* Plt ___
___ 08:30AM BLOOD Glucose-95 UreaN-7 Creat-0.3* Na-143
K-3.5 Cl-110* HCO3-20* AnGap-17
___ 08:30AM BLOOD Calcium-8.3* Phos-2.4* Mg-1.9
Microbiology:
Blood x2 (___): No growth
Urine (___): No growth
Blood x2 (___): No growth
Pathology:
Liver biopsy (___):
Liver, core needle biopsy (A):
Adenocarcinoma, involving the liver (see note).
Note: Immunohistochemical stains are performed. The tumor cells
are positive for CK20 and CDX-2, and negative for CK7 and TTF-1.
These results are consistent with metastasis from a colorectal
primary.
Imaging:
EKG (___):
Sinus tachycardia. Low voltage. Diffuse non-specific
repolarization
abnormalities. Compared to the previous tracing of ___
repolarization
abnormalities are slightly more prominent.
___
___
Portable CXR (___):
Innumerable pulmonary metastases. Possible mild pulmonary
vascular
congestion. Low lung volumes.
CTA (___):
1. No central or segmental filling defect in the pulmonary
arteries.
Evaluation is slightly limited due to suboptimal IV bolus.
2. Innumerable bilateral pulmonary nodules, simas seen on the
prior CT study on ___, slightly increased. No focal
consolidation or pleural effusion.
3. Enlarged liver with multiple hypodense lesions, with
suggestion of
increased burden of disease.
Right upper quadrant ultrasound (___):
Extensive diffuse hepatic metastatic disease. No evidence of
biliary duct
obstruction.
Portable CXR (___):
1. Low lung volumes and mild pulmonary vascular congestion is
unchanged.
2. New small right fissural pleural effusion.
3. No new focal opacities to suggest pneumonia.
Noncontrast head CT (___):
No acute intracranial process. No mass is identified. MRI is
more sensitive for evaluation of metastases.
Left hip XR (___):
No definite lytic lesion; however, an MRI can be performed to
evaluate for an osseous lesion if indicated.
Portable abdomen (___):
Radiographs of the abdomen and pelvis demonstrate a
nonobstructed
bowel gas pattern. A relative paucity of bowel gas is present
in the upper and mid abdomen, likely due to marked enlargement
of the liver, displacing bowel loops. Note that the upright
view is technically suboptimal, and limits evaluation for free
intraperitoneal air. If free intraperitoneal air is suspected
clinically, a left lateral decubitus view of the abdomen would
be recommended.
Brief Hospital Course:
Ms. ___ is a ___ with metastatic cancer of unknown primary,
including lesions in the liver and lungs, who initially
presented with shortness of breath, likely due to worsening
intrapulmonary tumor burden, and later underwent percutaneous
liver biopsy with pathology consistent with metastatic colon
cancer, prompting transfer to the oncology service and
eventually discharged home with hospice.
Active Issues:
(1) Metastatic colon adenocarcinoma: CTA to exclude pulmonary
embolus and right upper quadrant ultrasound on admission
demonstrated progression of previously recognized metastatic
cancer of unknown primary involving the liver and lungs, which
had evaded diagnosis in the outpatient setting due to patient
reluctance to engage with care. Percutaneous liver biopsy
ultimately revealed primary colonic adenocarcinoma. Following
discussion with her outpatient oncology providers, she was
transferred to the inpatient oncology service for potential
trial of FLOX. However, given the patient's very poor functional
and nutritional status a goals of care discussion was held with
the patient's HCP, ___ and it was decided to focus
goals of care of comfort and symptom management and the patient
was discharged home with home hospice.
(2) Left thigh weakness/spinous tenderness: She was found to
have focal left thigh weakness in association with diffuse
spinous tenderness of unclear chronicity in the setting of
preserved rectal tone without saddle anesthesia. She was noted
to be incontinent of urine, but not feces. Given underlying
malignancy, there was concern for bony metastases or cord
involvement, with alternative consideration given to epidural
abscess, prompting transient initiation of empiric antibiotic
coverage with vancomycin/cefepim ___ to ___. Despite
frequent persuasive efforts, she declined multiple attempts at
lumbosacral MRI, including with lorazepam premedication, citing
claustrophobia. Neuro exam was monitored and remained stable.
(3) Abdominal pain: She experienced intermittent abdominal pain
and tenderness without peritoneal signs, concerning for
obstruction in the setting of intraabdominal malignancy,
particularly given episodes of emesis/hematemesis as below.
While multiple KUBs were negative for obstruction, CT abdomen
was planned to evaluate for alternative sources of
intraabdominal pathology, but she declined on multiple
occasions. Pain was controlled with acetaminophen and tramadol
as needed.
(4) ? Hematemesis: She experienced a single episode of small
volume emesis, reportedly approximately 100cc, streaked with
blood and found to be guiac positive. Vital signs and hematocrit
remained stable. IV pantoprazole was initiated for
gastrointestinal prophylaxis, with subsequent discontinuation of
PPI given no recurrence and questionable if first episode was
true blood vs. red popsicle was eating at time.
Esophagogastroduodenoscopy was deferred in the absence of
recurrent hematemesis; no prior EGDs were available in OMR.
(5) Altered mental status: She was intermittently altered
throughout admission, never oriented to more than person and
place, with occasional difficulty following simple commands as
compared to an uncertain baseline. Infectious work up, including
blood and urine cultures and CTA on admission with subsequent
CXRs, was unrevealing. Noncontrast head CT was negative for
acute intracranial process. Brain MRI for definitive exclusion
of metastases could not be obtained due to claustrophobia/MRI
aversion as above. ABG on ___ without signs of CO2 retention.
History of opiates making patient sleepy per HCP as possible
contributing factor and therefore these were discontinued.
Hepatic encephalopathy also on differential given metastatic
lesions to liver and asterixis on exam. AMS could also be ___
to severe depression. Mental status monitored and remained
stable and patient at baseline per HCP on discharge.
(6) Shortness of breath: She presented with acute onset
shortness of breath without frank hypoxia. CTA on admission was
negative for pulmonary embolus, though (subsegmental clot could
not be excluded definitively), pleural effusion, or focal
infiltrate. EKG and cardiac enzymes were reassuring against
acute coronary syndrome. Low voltages on EKG were consistent
with prior, hence limited suspicion for pericardial effusion.
Shortness of breath resolved over the course of admission
without dedicated treatment, with the exception of nebulizers
and expectorants as needed.
(7) Leukocytosis: White blood cell count was elevated and peaked
at 20.6, consistent with recent baseline, likely reflecting
underlying malignancy. As noted above, infectious work up
including CTA, urine and blood cultures, and CXRs, was
unrevealing. She remained afebrile, with the exception of
isolated transient fever to 100, with stable vital signs.
(8 )Liver function test abnormalities: AST remained elevated ___
to ___, alkaline phosphatase 260s to 380s, and total bilirubin
2.1 to 2.6, likely due to hepatic infiltration of malignancy.
Right upper quadrant ultrasound was negative for cholecystitis
or obstructive process. The possibility of superimposed
intraabdominal process, such as infection, could not be excluded
in the setting of abdominal pain with emesis as above, but she
declined CT for further evaluation.
(9) Elevated lactate: Lactate was found to be 2.7-3.8 throughout
admission despite copious IV fluids, likely reflecting
compromised hepatic clearance in the setting of malignant
infiltration.
(10) Sinus tachycardia: She remained persistently tachycardic
100s to 115s throughout admission in the setting of poor PO
intake, but incompletely responsive to copious IV fluids.
Tachycardia has been present since at least ___. Despite
concurrent leukocytosis and elevated lactate, there was no clear
infectious source, hence low suspicion for sepsis. Subsegmental
pulmonary embolus could not be excluded on the basis of
admission CTA, but shortness of breath was short lived, and she
was never hypoxic. Hematocrit remained stable without signs of
active bleeding, with the exception of transient hematemesis as
above.
(11) Depression: She appeared depressed with flat affect and
seeming anhedonia throughout admission, with underlying
depression likely affecting motivation to seek diagnosis and
treatment of known malignancy. She denied active suicidal
ideation and frequently declined home sertraline, particularly
prior to liver biopsy, believing that it was supposed to be held
preprocedurally despite explanation to the contrary. She was
seen by social work throughout admission.
(12) Normocytic anemia: Hematocrit remained stable and
consistent with recent baseline at 27 to 33 throughout
admission, seemingly due to anemia of chronic disease on the
basis of preadmission labs. Vital signs remained stable, with
the exception of persistent tachycardia, without signs of active
bleeding apart from isolated blood streaked emesis as above.
(13) Coagulopathy: INR of 1.2 to 1.8 was felt to reflect
synthetic dysfunction in the setting of hepatic infiltration of
malignancy, as well as poor oral intake. There were no signs of
active bleeding, with the exception of transient hematemesis as
above.
Transitional Issues:
-Patient discharge home with home hospice
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
2. BuPROPion 150 mg PO DAILY
3. Gabapentin 300 mg PO HS
4. Sertraline 200 mg PO DAILY
5. traZODONE 100 mg PO HS:PRN sleep
6. Ondansetron 4 mg PO Q8H:PRN nausea
7. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
8. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
please hold for sedation, RR<10
9. Enoxaparin Sodium 40 mg SC DAILY
Discharge Medications:
1. BuPROPion 150 mg PO DAILY
2. Ondansetron 4 mg PO Q8H:PRN nausea
3. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
4. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [___] 8.6 mg 1 tablet by mouth twice a
day Disp #*60 Tablet Refills:*0
5. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule,delayed ___ by
mouth Daily Disp #*30 Capsule Refills:*0
6. Hospital Bed
Bariatric Hospital Bed and
Therapeutic Mattress: BariMaxxII
7. Hospice Order
Please Screen and Admit to Hospice.
8. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
9. Docusate Sodium 100 mg PO BID
10. Sertraline 200 mg PO DAILY
11. traZODONE 100 mg PO HS:PRN sleep
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Metastatic colon adenocarcinoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking part in your care during your admission
to ___. As you know, you were
admitted for shortness of breath, likely due to your underlying
cancer, and there was no evidence of pneumonia or blood clot in
the blood vessels of your lungs. Your shortness of breath
resolved, but you were found to have weakness in your left thigh
and abdominal pain. You declined imaging studies for further
investigation of these findings. You underwent biopsy of your
liver that revealed that the cancer known to affect your liver
and lungs originated in your colon (large bowel). You were
transferred to the oncology service, but unfortunately
chemotherapy would do more harm for you than good. After a long
discussion with you and your health care proxy, it was decided
that you will go home to be with your family and loved ones. We
will also set up hospice services for you so that they can help
with any issues that arise while you are at home.
Followup Instructions:
___
|
10000980-DS-20 | 10,000,980 | 29,654,838 | DS | 20 | 2188-01-05 00:00:00 | 2188-01-06 20:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo woman with h/o hypertension, hyperlipidemia, diabetes
mellitus on insulin therapy, h/o cerebellar-medullary stroke in
___, CKD stage III-IV presenting with fatigue and dyspnea on
exertion (DOE) for a few weeks, markedly worse this morning.
Over the past few weeks, the patient noted DOE and shortness of
breath (SOB) even at rest. She has also felt more tired than
usual. She notes no respiratory issues like this before. She
cannot walk up stair due to DOE, and feels SOB after only a
short distance. She is unsure how long the episodes last, but
states that her breathing improves with albuterol which she gets
from her husband. She had a bad cough around a month ago, but
denies any recent fevers, chills, or night sweats. No chest
pain, nausea, or dizziness.
Past Medical History:
1. CAD RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
MI in ___
3. OTHER PAST MEDICAL HISTORY:
Hypertension
Hyperlipidemia
Diabetes mellitus on insulin therapy
h/o cerebellar-medullary stroke in ___
CKD stage III-IV
PVD
Social History:
___
Family History:
Denies cardiac family history. Family hx of DM and HTN;
otherwise non-contributory.
Physical Exam:
Admission exam:
GENERAL- Oriented x3. Mood, affect appropriate.
VS- T= 98.1 BP= 200/103 HR= 65 RR= 26 O2 sat= 100% on RA
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK- JVD to angle of mandible
CARDIAC- RR, normal S1, S2. No murmurs, rubs or gallops. No
thrills, lifts.
LUNGS- Kyphosis. Resp were labored, mild exp wheezes
bilaterally.
ABDOMEN- Soft, non-tender, not distended. Abd aorta not enlarged
by palpation. No abdominal bruits.
EXTREMITIES- No clubbing, cyanosis or edema. No femoral bruits.
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO- CNII-XII grossly intact. Strength ___ in LEs and UEs.
Diminished sensation along lateral aspect of left leg to light
touch
Discharge exam:
Lungs: CTAB
Otherwise unchanged
Pertinent Results:
Admission Labs
___ 01:18PM BLOOD WBC-6.4# RBC-3.15* Hgb-9.5* Hct-30.1*
MCV-96 MCH-30.1 MCHC-31.5 RDW-14.1 Plt ___
___ 01:18PM BLOOD Glucose-150* UreaN-33* Creat-1.6* Na-144
K-4.8 Cl-111* HCO3-18* AnGap-20
___ 01:18PM BLOOD CK(CPK)-245*
___ 01:18PM BLOOD cTropnT-0.05*
___ 01:18PM BLOOD CK-MB-6 proBNP-4571*
___ 03:56AM BLOOD Calcium-9.4 Phos-4.9* Mg-2.0 Cholest-230*
Pertinent Labs
___ 06:09AM BLOOD WBC-4.3 RBC-3.27* Hgb-9.9* Hct-31.4*
MCV-96 MCH-30.4 MCHC-31.6 RDW-14.5 Plt ___
___ 06:09AM BLOOD Glucose-138* UreaN-31* Creat-1.4* Na-144
K-4.3 Cl-107 HCO3-26 AnGap-15
___ 06:09AM BLOOD ALT-20 AST-17
___ 03:56AM BLOOD Triglyc-97 HDL-65 CHOL/HD-3.5
LDLcalc-146*
___ 03:56AM BLOOD %HbA1c-8.1* eAG-186*
___ 01:18PM BLOOD CK(CPK)-245* CK-MB-6 cTropnT-0.05*
___ 08:43PM BLOOD CK(CPK)-198 CK-MB-5 cTropnT-0.03*
___ 03:56AM BLOOD CK(CPK)-173 CK-MB-5 cTropnT-0.04*
___ 06:09AM BLOOD cTropnT-0.01
___ 01:18PM proBNP-4571*
ECG ___ 7:56:06 ___
Baseline artifact. Sinus rhythm. The Q-T interval is 400
milliseconds. Q waves in leads V1-V2 with ST-T wave
abnormalities extending to lead V6. Consider prior anterior
myocardial infarction. Since the previous tracing of ___
atrial premature beats are not seen. The Q-T interval is
shorter. ST-T wave abnormalities are less prominent.
CXR ___:
PA and lateral views of the chest demonstrate low lung volumes.
Tiny bilateral pleural effusions are new since ___. No
signs of pneumonia or pulmonary vascular congestion. Heart is
top normal in size though this is stable. Aorta is markedly
tortuous, unchanged. Aortic arch calcifications are seen. There
is no pneumothorax. No focal consolidation. Partially imaged
upper abdomen is unremarkable.
IMPRESSION: Tiny pleural effusions, new. Otherwise unremarkable.
ECHO ___:
The left atrium is mildly dilated. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). Right ventricular chamber size and free wall motion are
normal. The diameters of aorta at the sinus, ascending and arch
levels are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No masses or
vegetations are seen on the aortic valve, but cannot be fully
excluded due to suboptimal image quality. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. An eccentric, anteriorly directed jet of
mild to moderate (___) mitral regurgitation is seen. Moderate
[2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. The end-diastolic
pulmonic regurgitation velocity is increased suggesting
pulmonary artery diastolic hypertension. There is an anterior
space which most likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global and regional biventricular
systolic function. Pulmonary artery hypertension. Mild-moderate
mitral regurgitation. Moderate tricuspid regurgitation.
Compared with the prior study (images reviewed) of ___, the
severity of mitral and tricuspid regurgitation are increased and
moderate PA hypertension is now identified.
Brief Hospital Course:
___ woman with h/o hypertension, hypelipidemia, diabetes
mellitus on insulin, cerebellar-medullary stroke in ___,
stage ___ CKD followed by Dr ___ presenting with fatigue and
DOE for a few weeks, markedly worse the morning of admission.
The patient has known diastolic dysfunction. Of note, she has
been noncompliant with her medications at home. On arrival to
the floor, she required hydralazine 20 mg to bring down her BP.
She has likely had elevated BPs at home for a while, which is
contributing to her SOB, CHF exacerbation, and secondary demand
myonecrosis (hypertensive urgency) with mildly elevated
troponin.
# CAD: Although she did not have a classic anginal presentation,
patient has several risk factors for acute coronary syndrome.
Her only symptom was SOB in the setting of elevated BPs
attributed to medication noncompliance at home. Her troponin
fell from 0.05 at admission to 0.01 at discharge in the setting
of renal dysfunction, but there was not a clear rise and fall to
suggest an acute infarction from plaque rupture and thrombosis.
She was scheduled for an outpatient stress test to evaluate for
evidence of ischemia from flow-limiting CAD. We decreased ASA to
81 mg from 325 mg daily to decrease the risk of bleeding. Her
LDL was found to be 146. We wanted to change her from
simvastatin to the more potent atorvastatin (and avoid issues
with drug-drug interactions), but her insurance would not cover
atorvastatin. She was therefore switched to pravastatin 80 mg at
discharge. From a cardiac standpoint, we did not feel that
Plavix was necessary for CAD, but her neurologist was contacted
and wanted Plavix continued. We had to stop metoprolol due to HR
in the ___ during admission even off metoprolol.
# Pump: Last echo in ___ showed low normal LVEF. Her current
presentation was consistent with CHF exacerbation with bilateral
pleural effusions, dyspnea, and elevated NT-Pro-BNP. Her TTE
showed mild-moderate mitral and moderate tricuspid
regurgitation, LVEF 50-55%, and pulmonary hypertension. We
changed her HCTZ to Lasix 40 mg PO at discharge. This medication
can be uptitrated as needed.
# Hypertension: The patient's nephrologist, Dr. ___, agreed
with our proposed medication adjustments, but recommended
staying away from clonidine. There has been a H/O medication
non-adherence. Social work was involved in discharge planning,
and ___ will be assisting the patient at home. We added
lisinopril 20 mg daily, Lasix 40 mg daily and continued
nifedipine 120 mg daily. Her atenolol was stopped due to her
renal dysfunction, but her metoprolol had to be stopped due to
bradycardia. She should continue on once a day medication dosing
to help with compliance.
# ? COPD: The patient may have a component of COPD as she was
wheezing on admission and responded to albuterol. She was given
a prescription for albuterol prn.
Transitional Issues:
- She will be scheduled for outpt stress stress test
- She has follow-up appointments with Dr. ___ and Dr.
___ and both can work on uptitrating her BP
meds as needed.
- ___ will need to work with patient on medication compliance.
Medications on Admission:
ATENOLOL - 100 mg Tablet - 1.5 Tablet(s) by mouth once a day
CLONIDINE - 0.1 mg/24 hour Patch Weekly - place on shoulder once
a week
CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 Tablet(s) by mouth once
a day generic is available preferable, please call Dr ___
an appointment
FENOFIBRATE MICRONIZED - 134 mg Capsule - 1 Capsule(s) by mouth
once a day
HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 (One) Tablet(s) by mouth
once a day
NIFEDIPINE [NIFEDIAC CC] - 60 mg Tablet Extended Release - 2
Tablet(s) by mouth once a day
NITROGLYCERIN [NITROSTAT] - 0.3 mg Tablet, Sublingual - 1
Tablet(s) sublingually sl as needed for prn chest pain may use 3
doses, 5 minutes apart; if no relief, ED visit
RANITIDINE HCL - 300 mg Tablet - 1 Tablet(s) by mouth once a day
SIMVASTATIN - 80 mg Tablet - 1 Tablet(s) by mouth at bedtime
Medications - OTC
ASPIRIN [ENTERIC COATED ASPIRIN] - 325 mg Tablet, Delayed
Release (E.C.) - 1 (One) Tablet(s) by mouth once a day
INSULIN NPH & REGULAR HUMAN [HUMULIN 70/30] - 100 unit/mL
(70-30) Suspension - 30 units at dinner at dinner
MULTIVITAMIN - (OTC) - Tablet - 1 Tablet(s) by mouth once a day
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Disp:*30 Tablet(s)* Refills:*2*
2. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
may take up to 3 over 15 minutes. Disp:*30 Tablet,
Sublingual(s)* Refills:*0*
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily). Disp:*60 Tablet(s)* Refills:*2*
5. pravastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Disp:*30 Tablet(s)* Refills:*2*
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2*
7. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. nifedipine 60 mg Tablet Extended Release Sig: Two (2) Tablet
Extended Release PO DAILY (Daily). Disp:*30 Tablet Extended
Release(s)* Refills:*2*
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. insulin NPH & regular human 100 unit/mL (70-30) Insulin Pen
Sig: Thirty (30) units Subcutaneous at dinner. Disp:*900 units*
Refills:*2*
11. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ puffs Inhalation every ___ hours as needed for shortness of
breath or wheezing. Disp:*1 inhaler* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-Hypertension with hypertensive urgency
-Myocardial infarction attributed to demand myonecrosis
-Acute on chronic left ventricular diastolic heart failure
-Chronic kidney disease, stage ___
-Chronic obstructive pulmonary disease
-Prior cerebellar-medullary stroke
-Hyperlipidemia
-Diabetes mellitus requiring insulin therapy
-Medication non-adherence
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for shortness of breath. You were found to
have elevated blood pressure on admission in the setting of not
taking all of your medications regularly. We obtained an
echocargiogram of your heart which showed some strain on your
heart possibly related to your elevated blood pressures.
You will be contacted about an outpatient stress test. This will
be completed within the next month.
You will be prescribed several new medications as shown below. A
visiting nurse ___ come to your home to help with managing your
medications. You should dispose of all your home medications and
only take the medications shown on this discharge paperwork.
Medications:
STOP Hydrochlorothiazide
STOP Simvastatin
STOP Clonidine
STOP Atenolol due to low heart rate
CHANGE 325mg to 81mg once daily
START Lisinopril 20mg once daily
START Lasix 40mg once daily
START Pravastin 80mg once daily
If you experience any chest pain, excessive shortness of breath,
or any other symptoms concerning to you, please call or come
into the emergency department for further evaluation.
Thank you for allowing us at the ___ to participate in your care.
Followup Instructions:
___
|
10000980-DS-21 | 10,000,980 | 26,913,865 | DS | 21 | 2189-07-03 00:00:00 | 2189-07-03 19:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Cardiac catheterization ___
History of Present Illness:
This is a ___ M with history of diabetes, diastolic CHF,
hypertension, ?CAD, peripheral vascular disease, CKD presenting
with ___ days of increasing dyspnea and non-productive cough.
She denies fevers, chills, chest pain, nausea, vomiting. Did
report feeling somewhat wheezy. Denies leg swelling, has
possibly had a 2 lb weight gain. Denies missed medication doses.
Does report 2 pillow orthopnea last night. Her husband has also
been sick with a cough for the past day or so. She is a
non-smoker. She lives at home and has had no recent
hospitalizations or courses of antibiotics.
In the ED, initial vitals: 97.8 80 132/83 25 97% ra. CXR showed
probable RUL PNA. Normal WBC and lactate, Cr at baseline.
Troponin 0.09 with normal CK-MB. BNP 2826. She was started on
bipap due to tachypnea and increased work of breathing. She was
given 40mg IV lasix and started on vancomycin, cefepime and
levofloxacin.
On transfer, vitals were: 69 141/82 28 100% bipap
On arrival to the MICU, patient reports improved breathing on
bipap.
Review of systems:
(+) Per HPI
Past Medical History:
- hypertension
- diabetes
- hx CVA (cerebellar-medullary stroke in ___
- CAD (has never been cathed, hx of MI in ___
- peripheral arterial disease- claudication, followed by
vascular, managed conservatively
- stage IV CKD (baseline 2.5-2.8)
- GERD/esophageal rings
Social History:
___
Family History:
Niece had some sort of cancer. Otherwise, no family history of
cancer or early heart disease.
Physical Exam:
ADMISSION EXAM:
General- appears comfortable on BiPap
HEENT- PERRL, EOMI
Neck- difficult to assess JVP due to habitus and presence of
BiPap strap
CV- RRR, no gallops
Lungs- good air entry. diffuse crackles R>L, rhonchi in RUL.
scattered inspiratory wheezing
Abdomen- soft, NTND
Ext- trace edema, faint peripheral pulses
Neuro- A and O x 3, moving all 4 extremities. mildly decreased
strength in LLL
DISCHARGE EXAM:
VS: T98.9 BP144/83 P66 RR18 99RA 76.1kg
GENERAL: Laying in bed, sleeping. No acute distress.
HEENT: Moist mucous membranes.
NECK: Supple, unable to visualize JVP.
CARDIAC: Regular rate and rhythm. Normal S1, S2. No S3, S4. ___
systolic murmur.
LUNGS: Clear to auscultation bilaterally. No crackles, wheezes,
rhonchi.
ABDOMEN: +BS, soft, nondistended, nontender to palpation.
EXTREMITIES: Warm and well perfused. Pulses 2+. Trace peripheral
edema.
Pertinent Results:
ON ADMISSION:
___ 06:48AM BLOOD WBC-5.3 RBC-2.94* Hgb-9.5* Hct-27.3*
MCV-93 MCH-32.4* MCHC-34.9 RDW-13.5 Plt ___
___ 06:48AM BLOOD Neuts-65.6 ___ Monos-5.2 Eos-2.7
Baso-0.4
___ 08:03PM BLOOD ___ PTT-69.6* ___
___ 06:48AM BLOOD Glucose-89 UreaN-37* Creat-2.3* Na-144
K-3.9 Cl-109* HCO3-21* AnGap-18
___ 06:48AM BLOOD CK-MB-6 proBNP-2826*
___ 06:48AM BLOOD cTropnT-0.09*
___ 12:58PM BLOOD CK-MB-9 cTropnT-0.11*
___ 07:52AM BLOOD Lactate-1.7
___ 07:40AM URINE Color-Straw Appear-Clear Sp ___
___ 07:40AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
ON DISCHARGE:
___ 09:00AM BLOOD WBC-4.8 RBC-2.53* Hgb-8.0* Hct-23.6*
MCV-94 MCH-31.5 MCHC-33.7 RDW-12.9 Plt ___
___ 09:26AM BLOOD Glucose-121* UreaN-52* Creat-2.2* Na-142
K-4.5 Cl-108 HCO3-24 AnGap-15
___ 09:26AM BLOOD Calcium-9.9 Phos-4.8* Mg-2.5
CXR: ___
Right upper lobe pneumonia or mass. However, given right hilar
fullness, a mass resulting in post-obstructive pneumonia is
within the
differential. Recommend chest CT with intravenous contrast for
further
assessment.
TTE: ___
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
to moderate regional left ventricular systolic dysfunction with
near-akinesis of the inferior, inferolateral and basal lateral
segments. The remaining segments contract normally (LVEF =
35-40%). Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. An eccentric jet
of moderate to severe (3+) mitral regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mild to moderate regional left ventricular systolic
dysfunction, c/w CAD. Moderate to severe mitral regurgitation.
Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of ___,
regional LV wall motion abnormalities are new. Severity of
mitral regurgitation has increased.
CARDIAC CATH: ___
1. Selective coronary angiography of this right dominant system
revealed three vessel coronary artery disease. The LMCA had no
obstructive disease. The LAD had a moderate disease in the mid
artery and a diagonal branch had an 80% proximal lesion. The
Lcx had a 70% proximal lesion. The RCA was totally occluded
mid-vessel.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Recommend CABG evaluation
CT CHEST: ___
1. Diffuse confluent ground-glass opacities predominantly in
the right upper lobe and right lower lobe most likely represent
residual pulmonary edema, localized to the right lung because of
direction of jet in mitral
regurgitation.
2. Possible pulmonary hypertension.
3. Moderate coronary artery disease.
CAROTID US: ___
No evidence of hemodynamically significant internal carotid
stenosis on either side.
ECHO ___- PCI)
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild regional left ventricular systolic
dysfunction with inferior and infero-lateral hypokinesis. No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The mitral valve leaflets are
mildly thickened. An eccentric jet of mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
the LVEF has increased. The degree of MR seen has decreased.
Brief Hospital Course:
___ female with ___, HTN, diabetes, CKD presented with
increased dyspnea and non-productive cough without fevers or
elevated white count, initially admitted to ___ with concern
for pneumonia. However, was found to have ST-changes, enzyme
leak, new wall motion abnormality consistent with a recent
cardiac event and had no evidence of pneumonia (no fevers, wbc,
lactate, normal vitals, CXR with likely one sided pulmonary
edema from mitral regurgitation). She was seen by cardiology who
transferred the patient to cardiology floor.
# Acute systolic CHF exacerbation/mitral regurgitation:
Likely secondary to ischemic valvular disease resulting in
worsening mitral regurgitation. ECHO also with akinetic inferior
wall segments, which also supports an ischemic event. Cardiac
cath revealed 3 vessel disease. Patient was managed medically
with lasix, lisinopril, and metoprolol. Cardiac surgery was
consulted for possible CABG and mitral valve repair/replacement.
However, given her multiple comorbidities, she is extremely high
risk and surgery was deferred. Therefore, the decision was made
to revascularize the patient with PCI to see if the patient
would regain function of her mitral valve. Patient received a
bare metal stent in the LCx and plain old balloon angioplasty in
the diagonal artery. Repeat echo showed improvement of her
mitral regurgitation.
# NSTEMI/CAD:
As evidenced by EKG changes and troponin leak. Patient was
briefly started on a heparin drip prior to her first cardiac
catheterization. As above, cardiac catheterization revealed
3-vessel disease. Patient was initially medically managed with
aspirin, plavix, metoprolol, lisinopril, and atorvastatin. As
the patient would be too high risk for CABG, patient returned to
the cath lab and had a bare metal stent and POBA. She will
require plavix for at least 1 month.
# Hypertension: Patient remained normotensive. Continued
nifedipine at half of her home dose. Continued on lisinopril.
She was also started on metoprolol as above for CHF.
# Diabetes: Continued home insulin regime.
# CKD stage IV: Baseline Cr 2.5-2.8 per renal notes. Currently
at baseline.
# History of CVA: Continued home aspirin and clopidogrel.
# GERD: Continued home ranitidine.
TRANSITIONAL ISSUES:
* Will need follow up with a cardiologist. Patient will be
scheduled to follow up with the first available CMED
cardiologist.
* Will need plavix for at least one month (day of bare metal
stent placement = ___.
* Atorvastatin dose increased to 80mg (per pharmacy, her
insurance will cover. Her co-pay will be $10/month).
* Consider titrating nifedipine dose back to 120mg if still
hypertensive.
* Please recheck Chem7 at next appointment to evaluate for ___
secondary to dye received during cardiac catheterization.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 30 mg PO DAILY
2. NIFEdipine CR 60 mg PO DAILY
3. Ranitidine 300 mg PO DAILY
4. Pravastatin 80 mg PO DAILY
5. HumuLIN 70/30 (insulin NPH and regular human) 30 units
subcutaneous daily
6. Ferrous Sulfate 325 mg PO BID
7. Furosemide 40 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Nitroglycerin SL 0.3 mg SL PRN chest pain
10. DiphenhydrAMINE 25 mg PO HS:PRN insomnia
11. sevelamer CARBONATE 800 mg PO TID W/MEALS
12. Clopidogrel 75 mg PO DAILY (was not taking regularly)
13. Aspirin 81 mg PO DAILY
14. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. Lisinopril 30 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Ranitidine 300 mg PO DAILY
7. sevelamer CARBONATE 800 mg PO TID W/MEALS
8. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
9. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet extended release 24
hr(s) by mouth daily Disp #*30 Tablet Refills:*0
10. DiphenhydrAMINE 25 mg PO HS:PRN insomnia
11. HumuLIN 70/30 (insulin NPH and regular human) 30 units
subcutaneous daily
12. Nitroglycerin SL 0.3 mg SL PRN chest pain
13. Vitamin D ___ UNIT PO DAILY
14. NIFEdipine CR 60 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Severe mitral regurgitation
Coronary artery disease
SECONDARY DIAGNOSIS:
Hypertension
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. As you recall, you were admitted for shortness
of breath. This was because one of your heart valves was weak,
which caused fluid to build up in your lungs. Your heart valve
was weak because there was a blockage in one of your heart
arteries. You underwent a procedure, called cardiac
catheterization, which opened up the blocked arteries. Your
valve and heart are pumping much more efficiently now. We are
glad you are feeling better. Please weigh yourself every
morning, and call your MD if your weight goes up more than 3 lbs
over 24 hours.
Followup Instructions:
___
|
10000980-DS-23 | 10,000,980 | 25,242,409 | DS | 23 | 2191-04-11 00:00:00 | 2191-04-11 17:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
DVT
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
This is a ___ y/o female with PMHx significant for CAD, HTN, HLD,
T2DM, CKD stage IV, PVD (s/p in ___, left superficial femoral
artery), presents with lower Left leg numbness and pain since
yesterday evening. The numbness started last night in bed. The
onset was gradual, and it was associated with pain/cramping over
her lateral calf, radiating down into her foot. She has had sx
like this before, usually when resting or lying in bed, not with
exertion. She denies leg weakness at this time, and is able to
walk without assistance. Today the pain and numbness is
improved; residual numbness in her lateral calf. Denies hx DVT.
Denies spine sx: no trauma, no back pain, no incontinence, no
fevers/chills. No numbness elsewhere. Additionally, she denies
headache, visual changes, chest pain, chest pressure, chest
palpitations, shortness of breath abdominal pain, dysuria, or
diarrhea.
Past Medical History:
- hypertension
- diabetes
- hx CVA (cerebellar-medullary stroke in ___
- CAD (hx of MI in ___ BMS to circumflex and POBA ___
- peripheral arterial disease- claudication, followed by
vascular, managed conservatively
- stage IV CKD (baseline 2.1-2.6)
- GERD/esophageal rings
Social History:
___
Family History:
Niece had some sort of cancer. Father died in his ___ due to
lung disease. Mother died in her ___ due to an unknown cause.
No early CAD or sudden cardiac death. No other known history of
cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.7, 166/85, 59, 16, 100% on RA.
General: Pleasant affect, laying in bed, resting comfortably in
NAD.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Minimal bibasilar crackles improved with cough.
Abdomen: obese abdomen, soft, non-tender, non-distended, no
rebound or guarding.
Ext: Warm, well perfused, 1+ pulses, right calf swelling greater
than left calf swelling. No calf tenderness to palpation. Thick
toenails, dry skin along toes. Hallux valgus.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation.
DISCHARGE PHYSICAL EXAM
Vitals: Tmax 99.1 HR ___ BP 97-168/50s-70s RR 18 SpO2
97-100%RA
FSG 90-307
General: Pleasant affect, laying in bed, resting comfortably in
NAD.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: clear to auscultation in all fields without wheezes or
ronchi
Abdomen: obese abdomen, soft, non-tender, non-distended, no
rebound or guarding.
Ext: Warm, well perfused, dopplerable pulses ___ on RLE,
dopplerable ___ pulse on LLE, dopplerable DP pulse on LLE, R
radial pulse 2+, L radial pulse 1+, mild right calf swelling
greater than left calf swelling. No calf tenderness to
palpation. No pain to palpation on left dorsal and lateral foot
- callous present on left lateral foot. Thick toenails, dry skin
along toes. Non-tender indurated cord in left antecubital fossa.
Neuro: alert and oriented x 3, CNII-XII intact, ___ RUE, ___
strength LUE, ___ hip flexor strength, ___ dorsi and plantar
flexion of bilateral lower extremities (4+/5 on right lower
extremity, 4- on LLE), fine touch sensation on extremities
bilaterally
Pertinent Results:
ADMISSION LABS:
___ 02:45PM BLOOD WBC-5.1 RBC-2.50* Hgb-7.7* Hct-23.4*
MCV-94 MCH-30.8 MCHC-32.9 RDW-14.7 RDWSD-50.0* Plt ___
___ 02:45PM BLOOD Neuts-74.4* Lymphs-15.1* Monos-7.7
Eos-2.4 Baso-0.2 Im ___ AbsNeut-3.79 AbsLymp-0.77*
AbsMono-0.39 AbsEos-0.12 AbsBaso-0.01
___ 02:45PM BLOOD ___ PTT-26.1 ___
___ 02:45PM BLOOD Glucose-107* UreaN-72* Creat-2.9* Na-141
K-4.3 Cl-108 HCO3-21* AnGap-16
___ 02:45PM BLOOD calTIBC-303 Ferritn-153* TRF-233
PERTINENT LABS/IMAGING:
-She received 1U pRBCs on admission on ___ 07:00AM BLOOD WBC-6.0 RBC-2.83* Hgb-8.7* Hct-26.3*
MCV-93 MCH-30.7 MCHC-33.1 RDW-14.7 RDWSD-50.2* Plt ___
-She had one large episode of coffee ground emesis-
___ 05:10PM BLOOD WBC-5.6 RBC-2.44* Hgb-7.4* Hct-22.7*
MCV-93 MCH-30.3 MCHC-32.6 RDW-14.7 RDWSD-49.8* Plt ___
-She received 500cc NS and 2UpRBCs-
___ 07:45AM BLOOD WBC-5.7 RBC-3.49*# Hgb-10.7*# Hct-32.3*
MCV-93 MCH-30.7 MCHC-33.1 RDW-14.9 RDWSD-49.1* Plt ___
___ bilateral lower extremity doppler U/S
IMPRESSION:
1. Deep venous thrombosis in the bilateral posterior tibial
veins.
2. 2.0 x 1.3 x 1.8 cm right-sided ___ cyst.
EGD ___
Small amount of hematin without evidence of ulceration or active
bleeding seen at the GE junction.
The stomach is significantly deformed. Diffuse erythema and
superficial ulcerations in the stomach consistent with severe
gastritis. No active bleeding identified.
Medium hiatal hernia
Erythema and superficial ulcerations in the duodenal bulb
consistent with duodenitis.
Otherwise normal EGD to third part of the duodenum
___ Left upper extremity ultrasound
IMPRESSION:
1. No evidence of deep vein thrombosis in the left upper
extremity.
2. Likely evolving hematoma in the left antecubital fossa.
___ CT head non contrast
IMPRESSION: 1. No evidence of acute infarction, hemorrhage,
fractures.
DISCHARGE LABS:
___ 07:30AM BLOOD WBC-5.8 RBC-2.44* Hgb-7.4* Hct-22.9*
MCV-94 MCH-30.3 MCHC-32.3 RDW-14.6 RDWSD-50.2* Plt ___
___ 07:30AM BLOOD Plt ___
___ 07:30AM BLOOD Glucose-78 UreaN-45* Creat-1.7* Na-142
K-4.7 Cl-109* HCO3-20* AnGap-18
___:30AM BLOOD Calcium-9.4 Phos-4.5 Mg-2.0
___ 07:30AM BLOOD EDTA ___
Brief Hospital Course:
Outpatient Providers: ___ with PMHx significant for CAD, HTN,
HLD, T2DM, CKD stage IV, PVD (s/p in ___, left superficial
femoral artery), presents with lower left leg numbness and pain,
found to have bilateral unprovoked DVT. She was treated with a
heparin drip and had many bleeding events during her stay: she
developed an upper GIB, had an EGD, and was followed by GI
during her admission. The heparin drip was stopped and then
re-started once her coffee-ground emesis resolved. Her stools
were guiac positive, however no active blood was found on rectal
exam. GI felt that colonoscopy could be deferred to out patient.
Additionally she developed a left arm hematoma. The heparin drip
was stopped and then re-started once her hematoma was felt to be
stable. She had left radial as well as bilateral lower extremity
___ dopplerable pulses throughout admission. Hematology was
consulted after the patient developed a left arm hematoma and
the drip was slowly uptitrated as per their recommendations. She
was successfully bridged to coumadin with an INR on discharge of
2.0. She was discharged to rehab as per ___ recs.
Please see below for a more problem based/detailed summary and
transitional issues.
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___ y/o female with PMHx significant for CAD, HTN, HLD, T2DM, CKD
stage IV, PVD (s/p in ___, left superficial femoral artery),
presented with lower Left leg numbness and pain since yesterday
evening, with ultrasound bilateral lower extremities showing
bilateral posterior tibial veins DVT's.
# Unprovoked Bilateral DVTs: No clinical signs of PE on
admission or during stay, positive bilateral DVTs on LENIs. Pain
and swelling improved on anticoagulation. Patient was bridged
with heparin drip to therapeutic warfarin with INR goal ___. Due
to continually supratherapeutic PTT > 150 on heparin drip,
hematology was consulted and no further workup was deemed
necessary. Heparin drip was carefully uptitrated as needed.
Clopidogrel was stopped per outpatient cardiologist. Patient
will need age-appropriate cancer screening including colonoscopy
and mammogram. Patient will follow-up in ___ clinic for
anticoagulation management and should continue on warfarin for
at least 3 months.
# Upper GI bleed: Patient developed 1 episode large coffee
ground emesis while on heparin drip with PTT > 150. Received 2U
pRBCs. GI consulted and EGD showed gastritis and superficial
erosions but no active bleeding. Incidental finding of medium
sized hiatal hernia. Stool h. pylori antigen was negative. GI
recommended 8 weeks of high dose PPI.
# Left antecubital hematoma: Patient developed large left
antecubital hematoma in setting of phlebotomy and PTT > 150 on
heparin gtt. Heparin gtt held while hematoma improved. Repeat
h/h were stable.
# Acute on CKD Stage IV: Patient with creatinine of 2.9 on
admission with baseline 2.0-2.5. Improved with hydration. Home
lasix and lisinopril were initially held. Home lasix restarted
on discharge at 20mg daily.
# Normocytic Anemia: Patient has normocytic anemia. Rectal exam
in ED was guaiac negative. In past treated with aransep as well
as EPO. Etiology likely related to underlying CKD, however also
must consider slow GI bleed (patient has gastritis/duodenitis on
EGD but no evidence of active bleeding. Iron studies were
normal.
# HFpEF: Home furosemide and Lisinopril were held on admission
for ___ followed by GI bleed. Carvedilol and nifedine were held
in setting of GIB (see above). Nifedipine was restarted at 30mg
bid and lasix was decreased from 40mg to 20mg daily.
# CAD: hx of MI in ___ BMS to circumflex and POBA ___. Per
discussions with Dr. ___, patient's cardiologist,
clopidogrel was held given GI bleed and initiation of warfarin.
Lasix initially held as above, but restarted on discharge at
20mg daily. Home ASA, statin, and carvedilol were continued.
# HTN: Nifedipine was decreased to 30mg BID from 60mg BID given
multiple bleeding episodes and normal blood pressures. Home
carvedilol continued. Patient's nifedipine was decreased to 30mg
daily given acute bleed and SBPs in the ___
Lasix was decreased from 40 daily to 20 daily.
# Diabetes Mellitus: Stable on home 30 units 70/30 insulin at
bedtime.
TRANSITIONAL ISSUES:
- Out patient hypercoaguability work up including screening
colonoscopy (last in ___ and mammogram
- Patient will need to complete an 8 week course of high dose
PPI (started 40mg pantoprazole PO twice daily on ___ with
projected end date ___ for upper GI bleed likely from
gastritis.
- Patient's hypertension medications (Lisinopril and nifedipine)
were held due to upper GI bleed.
- Patient's furosemide was decreased to 20mg daily
- Patient's nifedipine was decreased to 30mg daily given acute
bleed and SBPs in the ___
- Patient was started on Coumadin. Clopidogrel was stopped per
cardiology. ASA 81mg was continued.
- Please address patient's home environment for fall risk given
recent "trip" at home and new anticoagulation.
- please ensure patient has outpatient anticoagulation follow-up
and management upon discharge from rehab
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Carvedilol 12.5 mg PO BID
5. Clopidogrel 75 mg PO DAILY
6. Furosemide 40 mg PO DAILY
7. Ranitidine 150 mg PO DAILY:PRN reflux
8. Aspirin 81 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Vitamin D ___ UNIT PO DAILY
11. NIFEdipine CR 60 mg PO BID
12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
13. 70/30 30 Units Dinner
Discharge Medications:
1. Allopurinol ___ mg PO EVERY OTHER DAY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Carvedilol 12.5 mg PO BID
5. 70/30 30 Units Dinner
6. Lisinopril 40 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. NIFEdipine CR 30 mg PO BID
9. Vitamin D ___ UNIT PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Gabapentin 100 mg PO QHS neuropathic pain
12. Pantoprazole 40 mg PO Q12H
13. Senna 8.6 mg PO BID constipation
14. Warfarin 5 mg PO DAILY16
please dose and adjust for INR
15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
16. Furosemide 20 mg PO DAILY
17. Polyethylene Glycol 17 g PO DAILY
18. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Deep vein thrombosis (DVT)
Secondary:
Upper GI bleed
L arm hematoma
Superficial thrombophlebitis, L antecubital fossa
Chronic kidney disease (Stage IV)
Peripheral vascular disease
Diabetes mellitus type II
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear ___,
It was a pleasure caring for you at ___. You were admitted for
leg swelling and pain. Diagnostic tests were performed and you
were diagnosed with deep vein thrombosis, blood clots in your
legs. You were treated with blood thinning medications that you
will continue at home. You had an episode of upper GI bleeding
during your stay for which you are being treated with medication
and you underwent an EGD. You developed a left arm hematoma as
well during your stay which will resolve on its own over time.
For your blood clots, you were started on a new drug called
warfarin. You will need to have your blood checked to adjust the
dosing. For your upper GI bleed, you were started on
Pantoprazole 40mg twice daily. You will continue this drug as an
outpatient for at least 8 weeks. Additionally, you will no
longer be taking Clopidogrel (Plavix), until you speak with your
cardiologist.
It was a pleasure taking care you during your hospital stay.
Best wishes,
Your ___ Care Team
Followup Instructions:
___
|
10000980-DS-24 | 10,000,980 | 25,911,675 | DS | 24 | 2191-05-24 00:00:00 | 2191-05-24 17:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fatigue, anemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with a past medical
history of type-2 DM, hypertension, stage IV CKD, CAD s/p
distant MI and bare metal stent, stroke, recent unprovoked DVTs
on Coumadin, and recent upper GI bleeding, who was sent to ___
by her physician for anemia (Hgb 6.5).
The patient was admitted to ___ in ___ with unprovoked
bilateral lower extremity DVTs. She was started on heparin as an
inpatient, but anticoagulation was complicated by severely
elevated PTT (>150) and upper GI bleed. Endoscopy was notable
for significant erythema, superficial ulceration, and gastritis
without active bleeding. She was placed on BID PPI prophylaxis.
She was eventually bridged to Coumadin for a planned 6 month
course. Her INR is managed by her rehab facility, and she is
followed by Dr. ___ in ___ clinic.
For the last two weeks she has noted increasing fatigue along
with shortness of breath, exertional sub-sternal chest pain
relieved with rest, and symmetrical lower extremity swelling.
During this period she reports that her appetite remained good,
and he bowel function was normal. She denies bloody stools or
dark stool. On ___ she presented to her PCP office from rehab
reporting increasing shortness of breath and fatigue. She was
found to have a Hgb of 6.5, with an unconcerning CXR. She was
sent to the ___ ED.
In the ED, her initial vitals were T: 97.5 P: 60 BP: 156/76 RR:
16 SPO2: 100% RA. Exam was notable for guiac negative stool.
Imaging was notable for:
"1. Nonocclusive deep vein thrombosis of one of the paired
posterior tibial veins bilaterally. The extent of thrombus
bilaterally has decreased. No new deep venous thrombosis in
either lower extremity.
2. Right complex ___ cyst."
The patient was transfused with 2 units of pRBCs, with
appropriate increase in Hgb to 9.0. Following transfusion, a
repeat CXR was notable for pulmonary edema with bilateral
pleural effusions. She was given 20mg PO Lasix and 40mg IV Lasix
in the ED. The decision was made to admit the patient for anemia
and flash pulmonary edema.
On the floor, vitals notable for T: 97.9 BP: 154/75 P: 65 R: 20
O2: 99RA FSBG: 76. She reports no acute complaints, and that her
shortness of breath has resolved. She denies chest pain,
dizziness, lightheadedness.
Past Medical History:
- hypertension
- diabetes
- hx CVA (cerebellar-medullary stroke in ___
- CAD (hx of MI in ___ BMS to circumflex and POBA ___
- peripheral arterial disease- claudication, followed by
vascular, managed conservatively
- stage IV CKD (baseline 2.1-2.6)
- GERD/esophageal rings
Social History:
___
Family History:
Niece had some sort of cancer. Father died in his ___ due to
lung disease. Mother died in her ___ due to an unknown cause.
No early CAD or sudden cardiac death. No other known history of
cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 97.9 BP: 154/75 P: 65 R: 20 O2: 99RA FSBG: ___
General: Overweight woman, alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Crackles to the mid-lungs bilaterally
CV: Regular rate and rhythm, normal S1 + S2, no murmurs or
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. 2+
pitting edema in dependent areas to the buttocks
Skin: no rashes noted
Neuro: ___ strength in deltoids, biceps, triceps, wrist
extensors, finger extensors, hip flexors, hamstrings,
quadriceps, gastrocs, tibialis anterior, bilaterally. Sensation
intact bilaterally.
PSYCH: Alert and fully oriented; normal mood and affect.
sometimes slow to respond and responding with repetitive answers
but otherwise appropriate
DISCHARGE PHYSICAL EXAM:
VS: T: 97.6 BP: 150s-160s/70s-80s P: 60s-70s RR: 18 SPO2: 100RA
General: Overweight woman, alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally
CV: Regular rate and rhythm, normal S1 + S2, no murmurs or
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. 1+
pitting edema in shins bilaterally
Skin: no rashes noted
Pertinent Results:
LABORATORY STUDIES ON ADMISSION
=============================================
___ 12:30PM WBC-4.4 RBC-2.03* HGB-6.5* HCT-20.6*
MCV-102*# MCH-32.0 MCHC-31.6* RDW-16.3* RDWSD-59.6*
___ 12:30PM ___
___ 12:30PM ALBUMIN-4.1 CALCIUM-9.2 PHOSPHATE-4.7*
IRON-61
___ 12:30PM calTIBC-303 FERRITIN-155* TRF-233
___ 12:30PM UREA N-42* CREAT-2.3* SODIUM-142
POTASSIUM-4.7 CHLORIDE-109* TOTAL CO2-23 ANION GAP-15
___ 04:50PM LD(___)-247 TOT BILI-0.2
___ 04:50PM HAPTOGLOB-188
IMAGING:
==============================================
LENIs (___)
1. Nonocclusive deep vein thrombosis of one of the paired
posterior tibial veins bilaterally. The extent of thrombus
bilaterally has decreased. No new deep venous thrombosis in
either lower extremity.
2. Right complex ___ cyst.
CXR (___):
1. New mild pulmonary edema with persistent small bilateral
pleural effusions.
2. Severe cardiomegaly is likely accentuated due to low lung
volumes and patient positioning.
CXR (___):
As compared to ___, the lung volumes have slightly
decreased. Signs of mild overinflation and moderate pleural
effusions persist. Moderate cardiomegaly. Elongation of the
descending aorta. No pneumonia.
LABORAROTY STUDIES ON DISCHARGE
==============================================
___ 05:45AM BLOOD WBC-3.4* RBC-2.93* Hgb-8.9* Hct-28.0*
MCV-96 MCH-30.4 MCHC-31.8* RDW-17.5* RDWSD-59.7* Plt ___
___ 05:45AM BLOOD ___ PTT-30.6 ___
___ 05:45AM BLOOD Glucose-116* UreaN-41* Creat-2.1* Na-144
K-4.0 Cl-108 HCO3-25 AnGap-15
___ 04:50PM BLOOD LD(LDH)-247 TotBili-0.2
___ 05:45AM BLOOD Calcium-9.4 Phos-4.7* Mg-1.7
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a past medical
history of type-2 DM, hypertension, stage IV CKD, CAD s/p
distant MI and bare metal stent, stroke, recent unprovoked DVTs
on Coumadin, and recent upper GI bleed, who was sent to ___ by
her physician for anemia.
# Anemia:
Patient presented with Hgb of 6.5, down from her recent baseline
of ~7.5 since her ___ hospitalization. Upon presentation she
had a new macrocytic anemia. Hemolysis labs were negative. She
received two units of packed red cells with an appropriate rise
in her Hgb to 9.0. Stool was guiac negative, with no reports of
dark stool or blood in stool. Her hemoglobin remained stable at
this level, there was no overt bleeding, and her stool was guiac
negative. After transfusion the patient reported significant
improvement in her shortness of breath and fatigue. Given her
history of gastritis and diverticulosis, a GI bleed was believed
responsible for her anemia. Patient should receive an
EGD/colonoscopy as an outpatient.
# Acute exacerbation of heart failure with preserved ejection
fraction:
The patient was also found to be slightly volume overloaded, and
was treated with 2x40mg IV Lasix, with good urine output and
symptomatic improvement. Her pulmonary edema and peripheral
edema resolved with diuresis.
CHRONIC ISSUES:
# Gastic ulceration:
Continued on home pantoprazole BID
# Hypertension:
Continued on home nifedipine, carvadilol, lisinopril.
# Stage IV Chronic Kidney Disease:
Creatinine remained at baseline (b/l Cr 2.1-2.6) during
admission.
TRANSITIONAL ISSUES
======================
--Patient's Anemia is thought to be due to slow GI bleed given
history of gastritis and diverticulosis. Please schedule
EGD/colonoscopy within the next month
--Patient continued on Coumadin for bilateral DVTs; please
continue to weigh the risks and benefits of anticoagulation
given history of bleed.
--Discharge weight: 167.7
# CONTACT: ___ ___
# CODE: full, confirmed
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Allopurinol ___ mg PO EVERY OTHER DAY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Carvedilol 12.5 mg PO BID
5. Lisinopril 40 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. NIFEdipine CR 30 mg PO BID
8. Vitamin D ___ UNIT PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Gabapentin 100 mg PO QHS neuropathic pain
11. Pantoprazole 40 mg PO Q12H
12. Senna 8.6 mg PO BID constipation
13. Warfarin 4 mg PO 3X/WEEK (___)
14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
15. Furosemide 20 mg PO DAILY
16. Polyethylene Glycol 17 g PO DAILY
17. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever
18. Warfarin 3 mg PO 4X/WEEK (___)
19. 70/30 30 Units Dinner
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever
RX *acetaminophen 325 mg ___ tablet(s) by mouth Q6H:PRN Disp
#*120 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet
Refills:*0
4. Carvedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
6. Gabapentin 100 mg PO QHS neuropathic pain
RX *gabapentin 100 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
7. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 capsule(s) by mouth daily Disp #*30 Capsule
Refills:*0
9. NIFEdipine CR 30 mg PO BID
RX *nifedipine 30 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
RX *nitroglycerin [Nitrostat] 0.3 mg 1 tablet(s) sublingually
Q5MIN:PRN Disp #*10 Tablet Refills:*0
11. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
12. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth
daily Refills:*0
13. Senna 8.6 mg PO BID constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*60 Capsule Refills:*0
14. Vitamin D ___ UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
15. Warfarin 4 mg PO 3X/WEEK (___)
RX *warfarin 4 mg 1 tablet(s) by mouth 3X/WEEK Disp #*30 Tablet
Refills:*0
16. Warfarin 3 mg PO 4X/WEEK (___)
RX *warfarin 3 mg 1 tablet(s) by mouth 4X/WEEK Disp #*30 Tablet
Refills:*0
17. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
18. Allopurinol ___ mg PO EVERY OTHER DAY
RX *allopurinol ___ mg 1 tablet(s) by mouth EVERY OTHER DAY Disp
#*30 Tablet Refills:*0
19. 70/30 30 Units Dinner
RX *insulin NPH and regular human [Humulin 70/30 KwikPen] 100
unit/mL (70-30) 30 units SC Take 30 Units before DINER Disp #*2
Package Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Anemia
Congestive heart failure exacerbation
Secondary diagnosis:
Hypertension
DMII on insulin
Coronary artery disease
Stage IV chronic kidney disease
Deep vein thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
It was a pleasure caring for you. You were admitted to the
hospital with fatigue, chest pain, and shortness of breath. You
were found to have too few red blood cells (anemia). We gave you
blood, and your symptoms improved. Additionally, you were found
to have too much fluid in your legs and lungs. We treated you
with a diuretic, which helped eliminate the fluid.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10000980-DS-25 | 10,000,980 | 29,659,838 | DS | 25 | 2191-07-19 00:00:00 | 2191-07-22 09:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of of HTN, CAD s/p DES with ischemic MR and
systolic dysfunction, ___ on torsemide, hx of DVT, who presents
with 4 days of dyspnea on exertion, leg swelling, and 10 weight
gain.
Of note, patient was seen in the Heart Failure Clinic with Dr.
___ on ___ where she noted that she has had
persistent dyspnea on exertion and PND after a lengthy prior
hospitalization for DVT/GIB. At that time she was started on
40mg po torsemide which initially improved her symptoms.
Over the holiday she indulged in a high salt diet and developed
slow-onset dyspnea on exertion. Denies any medication
noncompliance, chest pain, palpitations, palpitations. Describes
PND, worsening exercise tolerance (unable to walk >50 feet) and
orthopnea.
In the ED, patient was found to have 1+ bilateral lower
extremity edema, and have bibasilar crackles on exam. Patient
underwent CXR, BNP, and was given one dose of IV 40mg Lasix. In
the ED initial vitals were: 97.8 73 199/100 18 95% RA. Prior to
transfer, vitals were 74 188/95 18 100% RA. Patient's labs were
remarkable for sodium 146, Chloride 115, K 5.4, Bicarb 19, BUN
39, Creatinine 2.3. Patient had CK 229, with MB 6, Trop < 0.01.
Patient had BNP of 10,180. Patient also had Hgb 8.1, Hct 26.8,
Platelet 168, WBC 5.4. Urinalysis still pending upon discharge.
EKG: notable for SR 76, with LAD, TWI in the inferior leads
which appears unchanged from prior on ___
On the floor she is symptomatically improved since coming to the
ED.
Past Medical History:
- hypertension
- diabetes
- hx CVA (cerebellar-medullary stroke in ___
- CAD (hx of MI in ___ BMS to circumflex and POBA ___
- peripheral arterial disease- claudication, followed by
vascular, managed conservatively
- stage IV CKD (baseline 2.1-2.6)
- GERD/esophageal rings
Social History:
___
Family History:
Father died in his ___ due to lung disease. Mother died in her
___ due to an unknown cause. No early CAD or sudden cardiac
death. No other known history of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T=98.0 BP: 168/96 HR=67 RR=16 O2 sat=100% on 2L NC
Admission weight 178lbs
GENERAL: WDWN, obese, sitting upright in bed, in NAD. AOx3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 8cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2, +S3. No murmurs/rubs/gallops. No
thrills, lifts.
LUNGS: Resp were unlabored, no accessory muscle use, dyspneic at
the end of a long sentence. Bibasilar crackles ___ up thorax,
diffuse wheezing.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 2+ edema to shins. No femoral bruits.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAMINATION:
VS: T=98.0 BP: 135/72 HR=67 RR=16 O2 sat=100% on RA
weight: 74kg
GENERAL: WDWN, obese, sitting upright in bed, in NAD. AOx3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 7cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2, +S3. No murmurs/rubs/gallops. No
thrills, lifts.
LUNGS: Resp were unlabored, no accessory muscle use. Bibasilar
crackles trace, diffuse wheezing.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: dry. No femoral bruits.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION LABS
___ 11:55AM BLOOD WBC-5.4 RBC-2.63* Hgb-8.1* Hct-26.8*
MCV-102*# MCH-30.8 MCHC-30.2* RDW-17.2* RDWSD-64.7* Plt ___
___ 11:55AM BLOOD Neuts-80.6* Lymphs-11.2* Monos-5.0
Eos-2.4 Baso-0.2 Im ___ AbsNeut-4.38 AbsLymp-0.61*
AbsMono-0.27 AbsEos-0.13 AbsBaso-0.01
___ 12:45PM BLOOD ___ PTT-32.9 ___
___ 07:30AM BLOOD Ret Aut-2.4* Abs Ret-0.06
___ 11:55AM BLOOD Glucose-153* UreaN-39* Creat-2.3* Na-146*
K-5.4* Cl-115* HCO3-19* AnGap-17
___ 11:55AM BLOOD CK-MB-6 cTropnT-<0.01 ___
___ 07:38PM BLOOD CK-MB-6 cTropnT-<0.01
___ 11:55AM BLOOD Calcium-9.0 Phos-3.9 Mg-1.8
DISCHARGE LABS
=====
___ 07:10AM BLOOD WBC-3.9* RBC-2.81* Hgb-8.6* Hct-26.7*
MCV-95 MCH-30.6 MCHC-32.2 RDW-16.0* RDWSD-56.4* Plt ___
___ 07:10AM BLOOD ___
___ 07:10AM BLOOD Glucose-100 UreaN-37* Creat-1.9* Na-144
K-3.9 Cl-105 HCO3-29 AnGap-14
___ 07:10AM BLOOD Calcium-9.5 Phos-4.4 Mg-1.8
IMAGING
=====
___ CXR
FINDINGS:
There is mild pulmonary edema with superimposed region of more
confluent consolidation in the left upper lung. There are
possible small bilateral pleural effusions. Moderate
cardiomegaly is again seen as well as tortuosity of the
descending thoracic aorta. No acute osseous abnormalities.
IMPRESSION:
Mild pulmonary edema with superimposed left upper lung
consolidation, potentially more confluent edema versus
superimposed infection.
Brief Hospital Course:
___ year-old female with history of hypertension, CAD s/p DES
with ischemic MR and systolic dysfunction, ___, hx of DVT, who
admitted for CHF exacerbation.
# Acute on chronic decompensated heart failure: presented in the
setting of high salt diet with dyspnea on exertion, decreased
exercise tolerance, ___ edema, crackles on exam, elevated BNP to
10K, 8lbs above dry weight and pulmonary congestion on CXR.
Later discovered on pharmacy review that patient had not filled
torsemide after last outpatient Cardiology appointment where she
was instructed to start taking it. Troponins cycled and
negative. On admission, she was placed on a salt and fluid
restricted diet. She was diuresed with IV Lasix 80mg for 2 days
and then transitioned to po torsemide 40mg with steady weight
decline and net negative fluid balance of goal -___ and
stable renal function. Electrolytes repleted for goal Mg>2 and
K>4. She was continued on home carvedilol 12.5mg BID,
atorvastatin 80mg daily and lisinopril 40mg daily for blood
pressure control and increased home nifedipine CR from 30 to
60mg BID to achieve goal SBP <140. Discharged with close PCP and
___ to monitor weights and blood pressure
control.
# Hypertension: She was continued on home carvedilol 12.5mg BID,
atorvastatin 80mg daily and lisinopril 40mg daily for blood
pressure control and increased home nifedipine CR from 30 to
60mg BID to achieve goal SBP <140.
# Positive U/A: patient asymptomatic but with 32WBCs, ___,
+bacteria (although 3 epis). Asymptomatic with no
fevers/dysuria/malaise. Urine culture negative.
# Left upper lung consolidation: infiltrate per Radiology read
on admission CXR. No cough, fevers, leukocytosis. Rereviewed
with on-call radiologist who favored pulmonary edema with no
need for repeat imaging or PNA treatment unless clinically
indicated. Monitored without any significant clinical findings.
# DVT: anticoagulated on Coumadin goal 2.0-3.0, no signs of
thrombus on exam. Daily INR trended and continued on home
Coumadin 5mg daily.
# Anemia: no signs of external loss, specifically denying any
melena. Chronically anemic with baseline ___, presented with Hgb
8. Likely ___ renal disease and ACD however elevated MCV
indicates possible reticulocytosis. Altogether low suspicion for
GIB so Coumadin was continued. Reticulocytes 2.4 which is
inappropriate arguing against acute loss. Trended daily CBC with
noted uprising by discharge.
# Chronic kidney disease, stage IV- baseline ___, likely ___
HTN and DM. Renally dosed medications and trended Cr with no
significant change.
# HLD: continued home atorvastatin
# DM: held home 25U 70/30. Patient maintained on aspart ISS and
glargine qHS with good glycemic control.
TRANSITIONAL ISSUES
==================
CHF: diuresed with IV lasix, transitioned to po diuretics,
discharged home on 40mg po torsemide, to take in the AM and take
a banana. Pt complained of unilateral R-sided incomplete hearing
loss on day of discharge- was not felt to be related to
diuretics but would ___.
HTN: increased nifedipine CR to 60mg BID given elevated SBPs.
Please f/u at next appointments.
Anemia: multiple prior workups showing ACD. Hgb 8s during
admission
Prior DVT/PE: continued on warfarin, will need continued
monitoring
DM: stopped home 70/30 while in-house and put on
aspart/glargine, discharged on home regimen
Discharge weight: 74kg
Discharge Cr: 1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Carvedilol 12.5 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Gabapentin 100 mg PO QHS neuropathic pain
7. Lisinopril 40 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. NIFEdipine CR 30 mg PO BID
10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
11. Pantoprazole 40 mg PO Q12H
12. Polyethylene Glycol 17 g PO DAILY
13. Senna 8.6 mg PO BID constipation
14. Vitamin D ___ UNIT PO DAILY
15. Warfarin 5 mg PO DAILY16
16. Allopurinol ___ mg PO EVERY OTHER DAY
17. Torsemide 40 mg PO DAILY
18. HumuLIN 70/30 (insulin NPH and regular human) 100 unit/mL
(70-30) subcutaneous 25 units with dinner
Discharge Medications:
1. HumuLIN 70/30 (insulin NPH and regular human) 100 unit/mL
(70-30) subcutaneous 25 units with dinner
2. Warfarin 5 mg PO DAILY16
3. Vitamin D ___ UNIT PO DAILY
4. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever
5. Allopurinol ___ mg PO EVERY OTHER DAY
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Docusate Sodium 100 mg PO BID
9. Gabapentin 100 mg PO QHS neuropathic pain
10. Lisinopril 40 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
13. Polyethylene Glycol 17 g PO DAILY
14. Senna 8.6 mg PO BID constipation
15. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth once daily Disp #*60
Tablet Refills:*0
16. Pantoprazole 20 mg PO Q12H
17. Carvedilol 25 mg PO BID
18. NIFEdipine CR 60 mg PO BID
RX *nifedipine 20 mg 3 capsule(s) by mouth twice daily Disp
#*180 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Acute on chronic decompensated congestive Heart Failure
Hypertension
Secondary Diagnoses:
Anemia
Diabetes mellitus
Prior deep vein thrombosis
Chronic Kidney Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___,
___ were admitted to ___ for treatment of your congestive
heart failure and hypertension. ___ were given IV diuretics with
improvement in your symptoms, labs and exam. We increased one of
your blood pressure medications and continued your other home
medicines.
It was a pleasure taking care of ___ during your stay- we wish
___ all the best!
- Your ___ Team
Followup Instructions:
___
|
10001217-DS-4 | 10,001,217 | 24,597,018 | DS | 4 | 2157-11-25 00:00:00 | 2157-11-25 17:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Left hand and face numbness, left hand weakness and clumsiness,
fever, and headache.
Major Surgical or Invasive Procedure:
Right parietal craniotomy for abscess incision and drainage.
History of Present Illness:
Mrs. ___ is a ___ y/o F from ___ with history of MS
presents with headaches and left hand clumsiness. Patient states
that her headaches first presented on ___ of this week in
which she did not think much of, but on ___, developed left
hand clumsiness. She states that she had difficulty with
grasping objects and using her fingers. She also reported some
numbness in the hand. Today, she presented to the ED because she
was found to have a temperature of 101.7 in which she took
Tylenol and was normothermic after. Once in the ED, patient was
seen by neurology who recommended an MRI head. MRI head revealed
a R parietal lesion concerning for MS, metastatic disease, or
abscess. Neurosurgery was consulted for further evaluation.
She reports a mild headache, numbness on the left side of face
and difficulty using her left hand. She denies any recent travel
outside of ___ and the ___. or ingesting any raw or uncooked
meats. She also denies any changes in vision, dysarthria,
weakness, nausea, vomitting, diarrhea, cough, or chills.
Past Medical History:
Multiple sclerosis
Social History:
___
Family History:
Mother with pancreatic cancer, brother-lung cancer, two sisters
with brain cancer.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
O: T:99 BP:160/102 HR: 81 R: 16 O2Sats: 97% RA
Gen: WD/WN, comfortable, NAD.
HEENT: atraumatic, normocephalic
Pupils: 4-3mm bilaterally EOMs: intact
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength L FI ___, otherwise full power ___
throughout.
No pronator drift
Sensation: Intact to light touch
PHYSICAL EXAM ON DISCHARGE:
T:98.1 BP:133/95 HR: 95 RR: 18 O2Sats: 98% RA
Gen: WD/WN, comfortable, NAD.
HEENT: atraumatic, normocephalic, with right craniotomy
incision.
Pupils: 4-3mm bilaterally, EOMs: intact
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal
movements,tremors. Strength L FI ___, otherwise full power ___
throughout.
No pronator drift
Sensation: Intact to light touch
Pertinent Results:
___ MRI HEAD W/WO CONTRAST
IMPRESSION:
1. Ring-enhancing lesion identified in the area of the right
precentral
sulcus frontal lobe, with associated vasogenic edema, restricted
diffusion, possibly consistent with an abscess, other entities
cannot be completely ruled out such as metastases or primary
brain neoplasm.
2. Multiple FLAIR and T2 hyperintense lesions in the
subcortical white matter along the callososeptal region,
consistent with known multiple sclerosis disease.
___ MRI HEAD W/ CONTRAST
IMPRESSION: Unchanged ring-enhancing lesion identified in the
area of the
right precentral sulcus of the frontal lobe, with associated
vasogenic edema. The differential diagnosis again includes
possible abscess, other entities, however, cannot be completely
excluded.
___ NON CONTRAST HEAD CT
IMPRESSION:
1. Status post right parietal craniotomy with mixed density
lesion in the
right precentral sulcus and surrounding edema not significantly
changed from prior MR of ___ allowing for
difference in technique.
2. No acute intracranial hemorrhage or major vascular
territorial infarct.
3. Bifrontal subcortical white matter hypodensities compatible
with
underlying multiple sclerosis.
___ 2:37 am CSF;SPINAL FLUID TUBE #1.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
Brief Hospital Course:
Mrs. ___ presented to the ___ Emergency Department on
___ with left-sided numbness of her hand and face and left
hand clumsiness. She was evaluated in the ED and initially
believed to have an MS flare and she was evaluted by Neurology
service which resulted in the recommendation for an MRI brain.
The MRI was read to demonstrate a right parietal lesion
concerning for MS, metastatic disease or abscess. She was
admitted to Neurosurgery for further evaluation and treatment.
On ___, Mrs. ___ was taken to the OR for a right
parietal craniotomy with cordisectomy, drainage and irrigation
of brain abscess. She tolerated the procedure well. She was
taken to PACU to recover then to the ICU. ID recommmend
Vancomycin and Meropenem. Gram stain PRELIM: gram negative rods
and gram positive cocci in pairs and chains. Post operative head
CT showed post operative changes. On post operative exam she had
left arm weakness.
On ___ the patient continued on vancomycin and Meropenem.
WBC was elevated to 19.0 from 15.7 on ___. She was
transferred to the floor. Left arm weakness was slightly
improved. the patient reported lethargy and left leg weakness.
on exam the patient was sleepy but awake. she was oriented to
person place and time. right sided strength was ___ and left
upper extremity was ___ and left lower extremity was full except
for IP which was 5-. A stat NCHCT was performed which was
stable.
On ___, consent for picc line placement obtained, picc line
placed by IV nurse. She will continue with vanco and meropenum
IV. Final abcess culture result is still pending. Exam remains
stable.
On ___ ___ evaluated the patient and found that she continues
to have an unsteady gait and would not be safe to go home. They
planned to visit her again on ___ for re-evaluation and to
perform stair maneuvers with her. The final results on the
abcess culture was streptococcus Milleri. New ID recommendations
were to discontiniu Vanco and Meropenum, she was started on
Ceftriaxone 2 grams and and Flagyl Tid.
On ___, patient was re-evaluated by ___ and OT and cleared to be
discharged home with the assistance of a cane. They also
recommend services while patient is at home. She remained stable
on examination.
On ___, Mrs. ___ was seen and evaluated, she
complained of headache and a non-contrast head CT was ordered.
This showed the stable post-operative changes. Home services
were established and the patient was discharged.
Medications on Admission:
Ibuprofen
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
RX *acetaminophen 325 mg ___ tablet(s) by mouth every six (6)
hours Disp #*112 Tablet Refills:*0
2. CeftriaXONE 2 gm IV Q12H
RX *ceftriaxone 2 gram 2 gm IV every twelve (12) hours Disp #*84
Vial Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*45 Capsule Refills:*0
4. LeVETiracetam 1000 mg PO BID
RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice a
day Disp #*56 Tablet Refills:*0
5. MetRONIDAZOLE (FLagyl) 500 mg PO TID
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three
times a day Disp #*126 Tablet Refills:*0
6. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone [Oxecta] 5 mg 1 tablet, oral only(s) by mouth
every six (6) hours Disp #*168 Tablet Refills:*0
7. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush
RX *heparin lock flush (porcine) [heparin lock flush] 10 unit/mL
1 ml IV every eight (8) hours Disp #*126 Vial Refills:*0
8. Sodium Chloride 0.9% Flush 10 mL IV Q8H and PRN, line flush
Flush before and after each infusion of antibiotics.
RX *sodium chloride 0.9 % [Normal Saline Flush] 0.9 % 10 ml IV
q12 Disp #*168 Syringe Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Brain abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
**Your wound was closed with sutures. You may wash your hair
only after sutures and/or staples have been removed.
You may shower before this time using a shower cap to cover
your head.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
Followup Instructions:
___
|
10001338-DS-8 | 10,001,338 | 27,987,619 | DS | 8 | 2142-03-02 00:00:00 | 2142-03-02 16:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Colonoscopy with biopsy ___
History of Present Illness:
This patient is a ___ year old female with Hx of sigmoid
diverticulitis s/p resection in ___, who complains of RLQ
abdominal pain. The patient states that her pain began yesterday
afternoon, worsened overnight and causing her to present to the
ED around 3AM. She describes it as a "gnawing" pain,
nonradiating, constant and ___ intensity. She states this
feels similar to her episode of diverticulitis several years
ago, only is present on the other side of her abdomen. She
denies any fever, nausea, vomiting, SOB, Chest pain, BRBPR. She
does endorse subjective feeling of chills.
.
Prior to the current episode, the patient reports having a
"sinus infection" about 3 weeks ago that resolved over one week
ago. About 2 weeks ago she also began taking a low dose OCP in
order to treate perimenopausal cramping. On the second week she
started to have spotting, with intermittent bleeding and LH this
past week. She had an episode of diarrhea one week ago ___
morning), that was nonbloody and resolved on its own. Starting
on ___ she has had a feeling of "lightheadedness"
associated with diaphoresis and nausea.
.
In the ED, initial VS were: 8 97.2 88 117/64 18 100%. Patient
was given morphine 4 mg IV, dilaudid 0.5 mg IV x 6, zofran 4 mg
IV, and 3 L NS. She underwent bimanual exam that was reportedly
without signs of mass, CMT, or adnexal tenderness. Labs were
notable for a leukocytosis of 11, but were otherwise
unremarkable. CT abdomen showed normal appendix but thick-walled
cecum with appearance of possible mass. Pelvic ultrasound did
not show any source of her pain. As she did not have adequate
relief with pain medications, she was admitted to the medical
service for pain control.
.
Vitals on transfer were 97.2 68 98/55 18 100%RA
.
On the floor, patient reported continued ___ pain in the RLQ,
along with some mild nausea.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied vomiting, diarrhea,
constipation or BRBPR. No dysuria. Denied arthralgias or
myalgias.
Past Medical History:
Hx diverticulitis s/p sigmoid resection ___
Anxiety
Allergic rhinitis
GERD
Eczema
Migraine headaches
Eustacian tube dysfunction
Social History:
___
Family History:
Father with hx of colitis, F died lung Ca, Aunt with breast ___,
Paternal GM with stomach Ca, Mother with CHF and DM2
Physical Exam:
Vitals: T: 97.6 BP: 96/62 P: 68 R:18 O2: 99% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended, bowel sounds present, TTP in RLQ
with deep palpation only, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Laboratory Findings:
___ 03:30AM BLOOD WBC-11.3* RBC-3.93* Hgb-12.2 Hct-34.9*
MCV-89 MCH-31.0 MCHC-34.8 RDW-12.8 Plt ___
___ 03:30AM BLOOD Neuts-76.5* ___ Monos-2.8 Eos-1.8
Baso-0.4
___ 05:26AM BLOOD ___
___ 03:30AM BLOOD Glucose-123* UreaN-16 Creat-0.8 Na-137
K-4.6 Cl-101 HCO3-25 AnGap-16
___ 03:30AM BLOOD ALT-16 AST-37 AlkPhos-36 TotBili-0.5
___ 03:30AM BLOOD Lipase-28
___ 05:27AM BLOOD Calcium-8.3* Phos-2.0*# Mg-2.0
___ 03:39AM BLOOD Lactate-0.9
___ 05:26AM BLOOD WBC-5.4 RBC-3.41* Hgb-10.6* Hct-30.6*
MCV-90 MCH-31.1 MCHC-34.7 RDW-12.5 Plt ___
___ 05:26AM BLOOD Glucose-88 UreaN-5* Creat-0.7 Na-144
K-4.1 Cl-106 HCO3-28 AnGap-14
___ 03:30AM URINE Color-Straw Appear-Clear Sp ___
___ 03:30AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
___ 03:30AM URINE RBC-<1 WBC-3 Bacteri-FEW Yeast-NONE Epi-0
Microbiology:
URINE CULTURE (Final ___: <10,000 organisms/ml
Blood Culture ___: No growth (not final at time of
discharge)
Imaging:
Pelvic U/S ___: FINDINGS: Transabdominally the uterus measures
8.6 x 4.6 x 5.4 cm, and is slightly heterogeneous in appearance
with no distinct fibroids seen. Transvaginal exam was performed
for better evaluation of the uterus and adnexa. The endometrial
stripe measures 5 mm. The left ovary measures 3.5 x 1.6 x 1.8
cm. The right ovary measures 2.9 x 1.4 x 1.7 cm. There is a
small echogenic focus within the right ovary measuring 5 x 4 x 4
mm, likely a small hemorrhagic cyst. Both ovaries demonstrate
normal arterial and venous waveforms.
IMPRESSION:
1. No evidence of ovarian torsion.
2. Small right ovarian hemorrhagic cyst.
.
CT abd/pelvis w/o contrast ___: Scattered calcified
granulomas in
the lung bases are stable. There is no new focal pulmonary
nodule,
consolidation, or effusion. The cardiac apex is within normal
limits.
Complete evaluation of the intra-abdominal viscera is limited by
the
non-contrast technique. However, the liver appears homogeneous
without focal lesion. No intra- or extra-hepatic biliary ductal
dilatation is identified. The gallbladder, spleen, and pancreas
appear within normal limits. The adrenal glands are symmetric
without focal nodule. The kidneys appear homogeneous without
focal lesion or hydronephrosis. The abdominal aorta is
non-aneurysmal throughout its visualized course. The second and
third portions of the duodenum are equivocally thickened which
may be due to underdistension. No small bowel obstruction is
identified. The appendix is well visualized and is normal in
appearance. There is no free fluid or free air.
CT PELVIS WITHOUT INTRAVENOUS CONTRAST ___: Initial images
demonstrated a solid mass like abnormality in the cecal tip
measuring approximately 3 cm (2:51). As this was potentially
concerning for a cecal mass, rescanning of a limited portion of
pelvis was performed after passage of oral contrast, confirming
the finding and demonstrating a 3 cm mass with thickening of the
adjacent cecal wall (601:15). The adjacent appendix is normal
and there is no pericecal inflammatory change.
The remainder of the colon is normal without evidence of
obstruction or
inflammation. The surgical anastomosis within the lower midline
pelvis
appears unremarkable. There is no pelvic free fluid. The uterus
and adnexa
appear within normal limits. The bladder is markedly distended
but is
otherwise unremarkable. No pathologically enlarged pelvic or
inguinal lymph nodes are identified.
OSSEOUS STRUCTURES: No bone destructive lesion or acute fracture
is
identified.
IMPRESSION:
1. Findings consistent with a 3 cm cecal mass and thickening of
the cecal tip concerning for neoplasm. Atypical infectious
process causing this appearance is felt less likely due to lack
of inflammatory stranding. Recommend colonoscopy for further
evaluation.
2. Normal appendix, no signs of inflammation.
3. No small or large bowel obstruction.
4. Equivocal thickening of duodenum likely related to
underdistention.
Colonoscopy ___:
Findings:
Lumen: Evidence of a previous end to end ___
anastomosis was seen at the sigmoid colon.
Protruding Lesions A ulcerated 3 cm mass of malignant
appearance was found in the cecum. The scope traversed the
lesion. Cold forceps biopsies were performed for histology at
the cecum.
Excavated Lesions Multiple diverticula with small openings were
seen in the descending colon.
Impression: Mass in the cecum (biopsy)
Diverticulosis of the descending colon
Previous end to end ___ anastomosis of the sigmoid
colon
Otherwise normal colonoscopy to cecum and terminal ileum
.
PATHOLOGY:
DIAGNOSIS:
"Cecal mass", mucosal biopsies:
Colonic mucosa with focal ischemic change and abundant
associated ulceration, exudate, and granulation tissue
formation; no carcinoma or dysplasia in these samples. Five
levels are examined.
Brief Hospital Course:
The patient is a ___ year-old female with history significant for
diverticulitis s/p sigmoid resection in ___, who presented with
abdominal pain and was found to have cecal mass.
.
# Abdominal pain: Was most likely related to hemorrhagic ovarian
cyst. Initially, patient had significant pain that was not
relieved with dilaudid. However, over the course of several
days her pain resolved on its own and she no longer required any
pain medications. Bloodwork and imaging were not suggestive of
any intra-abdominal infection. The patient was advised to
follow-up with her gynecologist regarding her ovarian cyst, and
the need for continued therapy with low dose oral contraceptive.
.
# Cecal Mass: During the workup of this patient's abdominal
pain, a CT of the abdomen and pelvis revealed a 3 cm cecal mass
concerning for malignancy. During this hospitalization she
underwent colonoscopy with biopsy of the mass. She was
instructed to follow-up with her outpatient gastroenterologist
regarding the results of this biopsy in one week. The biopsy
was negative for malignancy.
.
# Anxiety - Patient was continued on home regimen of zoloft and
ativan.
.
# Gerd - Patient continued on omeprazole, zantac BID per
outpatient regimen.
Medications on Admission:
-Fish Oil 1,000 mg Cap
-Axert 12.5 mg Tab
1 Tablet(s) by mouth at onset of HA may repeat in 2 hour up till
2 a day
-Lexapro 10 mg Tab daily
-Cholecalciferol (Vitamin D3) 1,000 unit Tab
-lorazepam 0.5 mg Tab qd prn
-Omeprazole 20 mg Cap, Delayed Release BID
-tramadol 50 mg Tab every six (6) hours as needed for pain
-oxycodone 5 mg Tab
___ Tablet(s) by mouth qhs prn as needed for pain
-Multivitamin Cap
-Zantac 150 mg Cap 1 Capsule(s) by mouth twice a day
-Fluticasone 50 mcg/Actuation Nasal Spray, Susp
2 sprays(s) intranasally for 7d, then 1 spray qd
-Calcium Citrate 1,000 mg Tab
-OCPs - Camrasce? started 2 weeks ago
Discharge Medications:
1. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Axert 12.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for migraine.
3. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for anxiety.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
10. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: Two
(2) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Cecal Mass
Hemorrhagic ovarian cyst
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital for abdominal pain, which we
think was related to a hemorrhagic ovarian cyst. You were
treated with analgesics, and your pain resolved. You also had a
CAT scan showing a mass in the cecum. You underwent a
colonoscopy to biopsy this mass, and you should follow-up with
your gastroenterologist.
You should also see your gynecologist regarding the need to
restart your oral contraceptive.
We did not make any changes to your home medications.
Followup Instructions:
___
|
10001401-DS-18 | 10,001,401 | 26,840,593 | DS | 18 | 2131-07-02 00:00:00 | 2131-07-08 09:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain, distention, nausea
Major Surgical or Invasive Procedure:
Interventional radiology placement of abdominal abscess drain
History of Present Illness:
___ F with h/o muscle invasive bladder cancer, returning to
the ED POD 15 with abdominal pain, nausea, and distension. She
has been obstipated for nearly three days. KUB and CT scan
notable for dilated loops, air fluids, and tapering small bowel
without an obvious transition point. Labwork notable for ___
and
leukocytosis. Concerned for small bowel obstruction or an ileus
in presence ___ and leukocytosis she was re-admitted for IVF,
bowel rest, NGT decompression.
Past Medical History:
Hypertension, laparoscopic cholecystectomy, left knee
replacement six to ___ years ago, laminectomy of L5-S1 at age
___, two vaginal deliveries.
s/p ___:
1. Robot-assisted laparoscopic bilateral pelvic lymph node
dissection.
2. Robot-assisted hysterectomy and bilateral oophorectomy for
large uterus, greater than 300 grams, with large fibroid.
3. Laparoscopic radical cystectomy and anterior vaginectomy with
vaginal reconstruction.
Social History:
___
Family History:
Negative for bladder CA.
Physical Exam:
WdWn, NAD, AVSS
Abdomen soft, appropriately tender along incision
Incision is c/d/I
Stoma is well perfused; Urine color is yellow
Bilateral lower extremities are warm, dry, well perfused. There
is no reported calf pain to deep palpation. Bilateral lower
extremities have 2+ pitting edema but no erythema, callor, pain.
Pigtail drain has been removed - dressing c/d/i
Pertinent Results:
___ 05:58AM BLOOD WBC-9.9 RBC-2.76* Hgb-8.2* Hct-26.2*
MCV-95 MCH-29.7 MCHC-31.3* RDW-13.9 RDWSD-47.3* Plt ___
___ 06:45AM BLOOD WBC-10.3* RBC-2.87* Hgb-8.7* Hct-27.7*
MCV-97 MCH-30.3 MCHC-31.4* RDW-14.0 RDWSD-49.4* Plt ___
___ 05:13AM BLOOD WBC-11.6* RBC-3.27* Hgb-9.8* Hct-31.0*
MCV-95 MCH-30.0 MCHC-31.6* RDW-13.6 RDWSD-47.5* Plt ___
___ 07:06PM BLOOD WBC-22.5*# RBC-3.58* Hgb-10.9* Hct-34.0
MCV-95 MCH-30.4 MCHC-32.1 RDW-13.9 RDWSD-47.9* Plt ___
___ 07:06PM BLOOD Neuts-89* Bands-1 Lymphs-5* Monos-3*
Eos-0 Baso-0 ___ Metas-1* Myelos-0 Hyperse-1* AbsNeut-20.48*
AbsLymp-1.13* AbsMono-0.68 AbsEos-0.00* AbsBaso-0.00*
___ 01:04PM BLOOD ___ PTT-30.9 ___
___ 05:58AM BLOOD Glucose-106* UreaN-26* Creat-0.4 Na-136
K-4.6 Cl-107 HCO3-26 AnGap-8
___ 06:45AM BLOOD Glucose-114* UreaN-32* Creat-0.4 Na-137
K-4.1 Cl-106 HCO3-25 AnGap-10
___ 06:00AM BLOOD Glucose-121* UreaN-39* Creat-0.4 Na-140
K-3.6 Cl-107 HCO3-26 AnGap-11
___ 07:06PM BLOOD Glucose-117* UreaN-60* Creat-1.7*# Na-133
K-5.0 Cl-96 HCO3-21* AnGap-21*
___ 08:30AM BLOOD ALT-20 AST-19 AlkPhos-77
___ 05:58AM BLOOD Calcium-7.6* Phos-2.8 Mg-2.2
___ 06:45AM BLOOD Calcium-7.7* Phos-2.4* Mg-2.1
___ 08:30AM BLOOD Albumin-1.8* Calcium-7.7* Phos-3.5 Mg-2.1
Iron-23*
___ 07:06PM BLOOD Calcium-8.0* Phos-5.5* Mg-2.2
___ 08:30AM BLOOD calTIBC-116* Ferritn-789* TRF-89*
___ 05:09AM BLOOD Triglyc-106
___ 08:30AM BLOOD Triglyc-89
___ 07:06PM BLOOD Lactate-1.5
___ 03:00PM ASCITES Creat-0.4 Amylase-18 Triglyc-29
Lipase-8
___ 03:00PM OTHER BODY FLUID Creat-0.5
___ 7:12 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
CITROBACTER KOSERI. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER KOSERI
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Aerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ ___, @14:35 ON
___.
___ 3:00 pm ABSCESS . PELVIC ASPIRATION.
**FINAL REPORT ___
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___:
BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH.
BETA LACTAMASE POSITIVE.
___ 10:52 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
Brief Hospital Course:
Ms. ___ was admitted to Dr. ___ service for
management of ileus. Upon admission, a nasogastric tube was
placed for decompression. On ___, PICC was placed and TPN
started. Blood cultures grew gram negative rods and ceftriaxone
was started. On ___, pt started to pass small amount of
flatus. ___ CT scan demonstrated improving ileus, but concern
for possible urine leak and increased free fluid. On ___, a
LLQ drain was placed by interventional radiology. on ___, pt
passed clamp trial and NGT was removed. Pt continued to pass
flatus and also started to have bowel movements. On ___, pt
was advanced to a clear liquid diet. Repeat blood cultures were
negative and positive blood culture from admission grew
citrobacter. Diet was gradually advanced and ensure added. IV
medications were gradually converted to PO and she was
re-evaluated by physical therapy for rehabilitative services.
She was ambulating with walker assistance and prepared for
discharge to her ___ facility (___). TPN was
continued up until day before discharge. At time of discharge,
she was tolerating regular diet, passing flatus regularly and
having bowel movements.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Levothyroxine Sodium 175 mcg PO DAILY
3. Losartan Potassium 50 mg PO DAILY
4. Acetaminophen 650 mg PO Q6H
5. Docusate Sodium 100 mg PO BID
6. Enoxaparin Sodium 40 mg SC DAILY
7. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY
8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
Last dose ___
2. MetroNIDAZOLE 500 mg PO Q6H Duration: 7 Days
Last dose ___
3. Senna 8.6 mg PO BID
4. Acetaminophen 650 mg PO Q6H
5. Atorvastatin 10 mg PO QPM
6. Docusate Sodium 100 mg PO BID
7. Enoxaparin Sodium 40 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
8. Levothyroxine Sodium 175 mcg PO DAILY
9. LORazepam 0.25 mg PO BID:PRN anxiety
10. Losartan Potassium 50 mg PO DAILY
11. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY
12. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
bladder cancer, post-operative ileus, bacteremia (CITROBACTER
KOSERI) and abdominal-pelvic abscess (BACTEROIDES FRAGILIS
GROUP) requiring ___ drainage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
-Please also refer to the instructions provided to you by the
Ostomy nurse specialist that details the required care and
management of your Urostomy
-Resume your pre-admission/home medications except as noted.
Always call to inform, review and discuss any medication changes
and your post-operative course with your primary care doctor
-___ (acetaminophen) and Ibuprofen for pain control.
-Ciprofloxacin and Metronidazole are new ANTIBIOTIC medications
to treat your infection. Continue for 7 days through ___.
-The MAXIMUM dose of Tylenol (ACETAMINOPHEN) is 3 grams (from
ALL sources) PER DAY
-If you are taking Ibuprofen (Brand names include ___
this should always be taken with food. If you develop stomach
pain or note black stool, stop the Ibuprofen.
-Please do NOT drive, operate dangerous machinery, or consume
alcohol while taking narcotic pain medications.
-Do NOT drive and until you are cleared to resume such
activities by your PCP or urologist. You may be a passenger
-Colace may have been prescribed to avoid post surgical
constipation and constipation related to narcotic pain
medication. Discontinue if loose stool or diarrhea develops.
Colace is a stool-softener, NOT a laxative.
-No heavy lifting for 4 weeks (no more than 10 pounds). Do "not"
be sedentary. Walk frequently. Light household chores (cooking,
folding laundry, washing dishes) are generally ok but AGAIN,
avoid straining, pulling, twisting (do NOT vacuum).
Followup Instructions:
___
|
10001401-DS-19 | 10,001,401 | 24,818,636 | DS | 19 | 2131-08-04 00:00:00 | 2131-08-04 15:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year old woman s/p robotic radical cystectomy
___ (with ileal conduit creation) with postop course
complicated by bacteremia and abscess, LLE DVT (on prophylactic
dosing lovenox) who presents with dyspnea on exertion for past 3
days.
Briefly, patient was initially admitted to the Urology service
from ___ for robotic anterior exenteration with ileal
conduit. She was discharged to rehab on prophylactic dosing
lovenox for 1 month. She was then readmitted from ___ for
ileus requiring NGT decompression, TPN. BCx grew Citrobacter,
for which CTX was started. CT showed intra-abdominal, interloop,
simple fluid collection and LLQ drain was placed by ___. Patient
improved, passing BMs and tolerating PO, and was discharged on
cipro/flagyl. She was also discharged on PO Bactrim for presumed
UTI, though unclear if she actually took this. During this
admission, she was noted to have new bilateral ___ edema. LENIs
at the time showed aute deep vein thrombosis of the duplicated
mid and distal left femoral veins. She was discharged on
Enoxaparin Sodium 40 mg SC daily. She reports that her PCP
started PO ___ 20mg daily and since then there has been
improvement of the swelling. Per her report, a repeat ___ at
the rehab facility (___) was negative for DVT.
Patient reports that she recovered well post-operatively and was
doing well at her assisted living facility up until a week ago
when she began experiencing dyspnea on exertion. She states that
she typically is able to ambulate a block before stopping to
catch her breath, however in the past week she has been unable
to take more than a few steps. She states that it has become
increasingly more difficult to ambulate from her bedroom to the
bathroom. When visited by the NP her ambulatory saturation was
noted to be in the ___ with associated tachycardia to 110,
pallor and diaphoresis. She endorses associated leg swelling
left worse than right, and she states that her thighs "feel
heavy". She denies any associated chest pain, fever, chills,
pain with deep inspiration, abdominal pain, rashes, dizziness,
lightheadedness.
In the ED, initial VS were: 97.7 72 136/93 20 100% Nasal Cannula
ED physical exam was recorded as patient resting comfortably
with NC, pursed lip breathing, unable to speak in full sentences
before becoming short of breath, urostomy pouch in RLQ, stoma
pink, 2+ edema to bilateral lower extremities L>R.
ED labs were notable for: Hb 9, Hct 29, plt 479, UA: large ___,
>182 WBC, many bact 0 epi. Trop neg x1, proBNP normal
CTA chest showed:
1. Extensive pulmonary embolism with thrombus seen extending
from the right main pulmonary artery into the segmental and
subsegmental right upper, middle, and lower lobe pulmonary
arteries. No right heart strain identified. 2. Additionally,
there are smaller pulmonary emboli seen in the segmental and
subsegmental branches of the left upper and lower lobes. 3.
Several pulmonary nodules are noted, as noted previously, with
the largest appearing spiculated and measuring up to 1 cm in the
right middle lobe, suspicious for malignancy on the previous
PET-CT. 4. Re- demonstration of 2 left breast nodules for which
correlation with mammography and ultrasound is suggested.
EKG showed NSR with frequent PAC
Patient was given:
___ 20:26 PO/NG Ciprofloxacin HCl 500 mg
___ 20:26 IV Heparin 6600 UNIT
___ 20:26 IV Heparin
Transfer VS were: 98.1 77 145/63 20 99% Nasal Cannula
When seen on the floor, she reports significant dyspnea with
minimal exertion. Denies chest pain, palpitations,
lightheadedness.
A ten point ROS was conducted and was negative except as above
in the HPI.
Past Medical History:
Hypertension, laparoscopic cholecystectomy, left knee
replacement six to ___ years ago, laminectomy of L5-S1 at age
___, two vaginal deliveries.
s/p ___:
1. Robot-assisted laparoscopic bilateral pelvic lymph node
dissection.
2. Robot-assisted hysterectomy and bilateral oophorectomy for
large uterus, greater than 300 grams, with large fibroid.
3. Laparoscopic radical cystectomy and anterior vaginectomy with
vaginal reconstruction.
Social History:
___
Family History:
Negative for bladder CA.
Physical Exam:
ADMISSION EXAM:
Gen: NAD, speaking in 3 word sentences, pursed lip breathing,
no accessory muscle use, lying in bed
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
Cardiovasc: RRR, no MRG, full pulses, 1+ edema bilaterally with
compression stockings in place, no JVD
Resp: normal effort, no accessory muscle use, lungs CTA ___ to
anterior auscultation.
GI: soft, NT, ND, BS+. Urostomy site does not appear infected
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. No facial droop.
Psych: Full range of affect
DISCHARGE EXAM:
vitals: 98.3 140/42 90 24 96% 1L
Gen: Lying in bed in no apparent distress
HEENT: Anicteric, MMM
Cardiovascular: RRR normal S1, S2, no right sided heave, ___
systolic murmur
Pulmonary: Lung fields clear to auscultation throughout. No
crackles or wheezing.
GI: Soft, distended, nontender, bowel sounds present, urostomy
in place.
Extremities: no edema, though left leg appears larger than right
leg, warm, well perfused with motor function intact. Her left
lower leg is wrapped.
Pertinent Results:
LABS:
==========================
Admission labs:
___ 02:40PM GLUCOSE-101* UREA N-22* CREAT-0.7 SODIUM-136
POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-22 ANION GAP-20
___ 02:40PM cTropnT-<0.01
___ 02:40PM proBNP-567
___ 02:40PM WBC-7.7 RBC-3.07* HGB-9.0* HCT-29.1* MCV-95
MCH-29.3 MCHC-30.9* RDW-14.9 RDWSD-52.1*
___ 02:40PM PLT COUNT-479*
___ 02:40PM ___ PTT-33.4 ___
Discharge labs:
___ 06:55AM BLOOD WBC-11.0* RBC-2.60* Hgb-7.5* Hct-24.5*
MCV-94 MCH-28.8 MCHC-30.6* RDW-14.8 RDWSD-51.4* Plt ___
___ 06:55AM BLOOD Glucose-99 UreaN-10 Creat-0.5 Na-141
K-4.3 Cl-105 HCO3-26 AnGap-14
___ 06:55AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.0
___ 07:15AM BLOOD calTIBC-134* Ferritn-507* TRF-103*
___ 07:15AM BLOOD Iron-18*
MICROBIOLOGY
==========================
___ 4:30 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
ENTEROCOCCUS SP.. >100,000 CFU/mL.
PREDOMINATING ORGANISM INTERPRET RESULTS WITH CAUTION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 1 S
IMAGING
==========================
___ CXR
IMPRESSION: Hilar congestion without frank edema. No convincing
signs of pneumonia.
___ CTA chest showed:
1. Extensive pulmonary embolism with thrombus seen extending
from the right main pulmonary artery into the segmental and
subsegmental right upper, middle, and lower lobe pulmonary
arteries. No right heart strain identified. 2. Additionally,
there are smaller pulmonary emboli seen in the segmental and
subsegmental branches of the left upper and lower lobes. 3.
Several pulmonary nodules are noted, as noted previously, with
the largest appearing spiculated and measuring up to 1 cm in the
right middle lobe, suspicious for malignancy on the previous
PET-CT. 4. Re- demonstration of 2 left breast nodules for which
correlation with mammography and ultrasound is suggested.
___ ___:
IMPRESSION:
1. Interval progression of deep vein thrombosis in the left
lower extremity, with occlusive thrombus involving the entire
femoral vein, previously only involving the mid and distal
femoral vein. There is additional nonocclusive thrombus in the
deep femoral vein. The left common femoral and popliteal veins
are patent.
2. The bilateral calf veins were not visualized due to an
overlying dressing. Otherwise no evidence of deep venous
thrombosis in the right lower extremity.
___ TTE:
Conclusions
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%).
Doppler parameters are most consistent with Grade I (mild) left
ventricular diastolic dysfunction. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
are mildly thickened (?#). There is no aortic valve stenosis.
Trivial mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension.
___ CXR
IMPRESSION:
Compared to chest radiographs ___ through ___.
Heart size top-normal. Lungs grossly clear. No pleural
abnormality or evidence of central lymph node enlargement.
Brief Hospital Course:
Ms. ___ is a ___ woman s/p robotic radical cystectomy
___omplicated by bacteremia and
abscess, LLE DVT, currently on daily lovenox who presents with
dyspnea on exertion and dyspnea on exertion and found to have
large PE and progression of DVT.
# PE/DVT: Likely due to undertreatment of known LLE DVT with
prophylactic dosing of lovenox. Given underdosing of lovenox,
this was not thought to be treatment failure and IVC filter was
deferred. She had no signs of right heart strain on imaging,
EKG, exam. TTE showed no evidence of right heart strain. She was
treated with a heparin gtt, then transitioned to treatment dose
lovenox given malignancy associated thrombosis as noted in CLOT
trial. She is quite symptomatic and requires oxygen
supplementation, though improved during hospitalization. Please
wean oxygen as tolerated.
# Pulmonary nodules: Known spiculated masses that were noted on
CT in ___, concerning for primary lung malignancy vs mets.
Current CT showed stable nodules still concerning for
malignancy. She was evaluated by the thoracic team who
recommended CT biopsy vs. surveillance. Given her current
PE/DVT, the family and the patient decided for surveillance at
this time. They will follow up with her primary care provider.
# Enterococcal UTI
She was noted to have rising WBC in the setting of UCX from
urostomy growing Enterococcus. Given her rising leukocytosis, we
proceeded with treatment. She was started on IV Ampicillin and
transitioned to macrobid, based on sensitivies. Leukocytosis
improved on antibiotics. She should complete a 7 day course (day
1: ___, day 7: ___.
# Normocytic Anemia: No signs of bleeding, or hemolysis. Hb
dropped to nadir of 7.3, stable at discharge at 7.5. Iron
studies consistent with likely combination iron deficiency
anemia and anemia of chronic disease with low iron but elevated
ferritin and low TIBC. Would recommend checking again as
outpatient and work-up as needed.
# ___ swelling: Likley multifactorial including venous
insufficiency, as well as known LLE DVT. She responded quite
well with compression stockings.
# Hx of bladder cancer: s/p ___ TURBT, high-grade TCC, T1
(no muscle identified). Then in ___, pelvic MRI showed
bladder mass invasion, perivesical soft tissue, anterior vaginal
wall on right (C/W T4 lesion). In ___, underwent robotic
TAH-BSO, lap radical cystectomy and anterior vaginectomy with
pathology showing pT2b, node and margins negative. No plan for
any further therapy at this time per Dr ___.
The patient is safe to discharge today, and >30min were spent on
discharge day management services.
Transitional issues:
- She will need follow up chest CT for pulmonary nodules in 3
months (___)
- To complete 7 day course for UTI with macrobid (day 7: ___
- Continue oxygen therapy and wean as tolerated to maintain O2
sat > 92%
- Please check CBC on ___ to ensure stability of h/h
and demonstrate resolution of leukocytosis
- HCP: son, Dr. ___ ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
4. Levothyroxine Sodium 175 mcg PO DAILY
5. Atorvastatin 10 mg PO QPM
6. Losartan Potassium 50 mg PO DAILY
7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
8. LORazepam 0.25 mg PO BID:PRN anxiety
9. Senna 8.6 mg PO BID
Discharge Medications:
1. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
Last day: ___. Enoxaparin Sodium 90 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
3. LORazepam 0.25 mg PO QHS:PRN insomnia
RX *lorazepam 0.5 mg 0.5 (One half) tab by mouth QHS:prn Disp
#*3 Tablet Refills:*0
4. Acetaminophen 650 mg PO Q6H
5. Atorvastatin 10 mg PO QPM
6. Docusate Sodium 100 mg PO BID
7. Levothyroxine Sodium 175 mcg PO DAILY
8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth Q8H:prn Disp #*3 Tablet
Refills:*0
9. Senna 8.6 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Ms. ___ it was a pleasure taking care you during your
admission to ___. You were admitted for a clot in your lungs
and leg. You were treated with a blood thinner. You will need to
continue the blood thinner. You were also treated for a urinary
tract infection. For your pulmonary nodules, you should follow
up with your primary care doctor.
Followup Instructions:
___
|
10001667-DS-10 | 10,001,667 | 22,672,901 | DS | 10 | 2173-08-24 00:00:00 | 2173-08-24 15:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
slurred speech
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old right-handed woman with hx of Atrial fibrillation on
Eliquis (only once daily), hypertension, hyperlipidemia, CHF
presents as transfer from OSH after she had acute onset
dysarthria and CTA showed possible partial thrombus or stenosis
in superior division of L MCA. Transferred here for closer
monitoring and possible thrombectomy if her exam acutely
worsens.
History obtained from patient and daughter at bedside. Patient
is an excellent historian.
On ___, she had dinner with friends and then returned to her
apartment and was fooling around on her computer. Last known
well
was around 8:00 ___. Then, she had an odd sensation and started
throwing her arms around. She went to living room to sit down
and
tried to read but could not see the words very clearly. Then,
two family members were knocking at the door and she had a tough
time
standing up to open door. She was able to eventually stand up
with great difficulty and walked with her walker. She usually
walks with a walker because of knee replacement. Finally, got up
out of chair with walker and walked to the door to unlock. She
noticed problems talking to family members. She had difficulty
forming words and pronouncing words. Denies word finding
difficulty. She could tell it was slurred like a person who had
too much to drink. EMTs asked if she was intoxicated but she was
not. She was very aware of her dysarthria and told her daughters
that she thinks she's having a stroke. Then, she said she had
trouble sitting down but has no idea why she thought that. When
she was standing, she was able to walk with walker but she felt
unsteady and almost fell. No visual changes. No numbness or
tingling. Denies focal weakness; she just had trouble standing
up. She was able to unlock her door without issue but she felt
shaky.
She was brought by EMS to ___ where NIHSS was 1 for
slurred speech. There, she felt the same but her symptoms
started to improve when she started to be transferred.
Paramedics said her speech was improving rapidly en route.
Last month, started needing naps. Her hearing is poor at
baseline and she normally uses hearing aids.
For the past ___ months, she has had ___ nocturia nightly. No
dysuria.
She has noticed more frequent headaches lately in the past ___
months. Last headache was yesterday. She takes tramadol and
acetaminophen up to a couple times a night. She reports
headaches at night which wake her up. She denies that the
headache is
positional; it is the same sitting up or lying down. She has had
some gradual weight loss over the past ~12 months; ___ year ago
she was almost 140 lbs, and now she is ___ lbs. Her appetite is
still good and she enjoys eating but she is less hungry that she
used to be.
Daughter says that she has had marked decline in memory in past
___ weeks. Over past few years, she has been forgetting plans,
times for pickpup, and dinner plans, which has become normal.
Over the past ___ weeks, family has noticed dramatic worsening.
She doesn't remember which grandkids were coming to visit when
she bought the plane tickets herself.
She endorses 2 pillow orthopnea.
Past Medical History:
Divertoculosis
Atrial fibrillation on Eliquis
CHF
Hypercholesterolemia
Hypertension
Social History:
___
Family History:
Father - severe alcoholic, schizophrenia
Mother - CHF
Brother - stroke, carotid stenosis
Physical Exam:
ADMISSION EXAM:
Vitals: T:97.9 HR: 79 BP: 164/121 RR: 19 SaO2: 94% on RA
General: Awake, cooperative elderly woman, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: ecchymoses in L shin, more extensive on R shin.
Neurologic:
-Mental Status: Alert, oriented ___.
Able to relate history without difficulty. Attentive, able to
name ___ backward without difficulty. Language is fluent with
intact repetition and comprehension. Normal prosody. There were
no paraphasic errors. Able to name both high and low frequency
objects. Able to read without difficulty. No dysarthria. Able
to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch and pinprick.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger snapping b/l. Did not bring her
hearing aids.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk and tone throughout. No pronator drift. No
adventitious movements, such as tremor or asterixis noted.
[___]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, temperature
throughout. Decreased vibratory sense in b/l feet up to ankles.
Joint position sense intact in b/l great toes. No extinction to
DSS. Romberg absent.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2+ 2 2 2+ 0
R 2+ 2 2 2+ 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. No dysmetria on FNF
bilaterally. HKS with L heel without dysmetria. Unable to bend R
knee due to knee surgery.
-Gait: unable to assess as patient needs a walker at baseline
DISCHARGE EXAM:
24 HR Data (last updated ___ @ 419)
Temp: 97.4 (Tm 98.6), BP: 146/76 (116-155/65-94), HR: 53
(53-86),
RR: 17 (___), O2 sat: 96% (92-97), O2 delivery: Ra
General: Awake, cooperative elderly woman, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: NR, RR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: ecchymoses in L shin, more extensive on R shin.
Neurologic:
-Mental Status: Alert, oriented to person and situation. Able to
relate history without difficulty. Attentive to examiner.
Language is fluent with intact comprehension. Normal prosody.
There were no paraphasic errors. No dysarthria. Able to follow
both midline and appendicular commands. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to conversation.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions.
-Motor: Normal bulk and tone throughout. No pronator drift. No
adventitious movements, such as tremor or asterixis noted.
[Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas]
L 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 * * 5 5
*Knee cannot bend after prior surgery
-Sensory: No deficits to light touch throughout.
-Coordination: No intention tremor. No dysmetria on FNF
bilaterally.
-Gait: needs a walker at baseline
Pertinent Results:
___ 01:50AM BLOOD WBC-7.2 RBC-4.75 Hgb-14.6 Hct-45.5*
MCV-96 MCH-30.7 MCHC-32.1 RDW-13.2 RDWSD-46.5* Plt ___
___ 01:50AM BLOOD Neuts-53.1 ___ Monos-8.2 Eos-1.5
Baso-0.3 Im ___ AbsNeut-3.81 AbsLymp-2.63 AbsMono-0.59
AbsEos-0.11 AbsBaso-0.02
___ 01:50AM BLOOD ___ PTT-29.7 ___
___ 01:50AM BLOOD Glucose-97 UreaN-18 Creat-0.7 Na-139
K-4.3 Cl-102 HCO3-26 AnGap-11
___ 07:35AM BLOOD CK-MB-4 cTropnT-<0.01
___ 07:35AM BLOOD Calcium-9.3 Phos-3.6 Mg-1.8 Cholest-207*
___ 07:35AM BLOOD Triglyc-62 HDL-69 CHOL/HD-3.0 LDLcalc-126
___ 10:57AM BLOOD %HbA1c-5.5 eAG-111
___ 05:22AM BLOOD VitB12-249
___ 05:22AM BLOOD TSH-5.8*
___ 05:22AM BLOOD Trep Ab-NEG
___ 03:12AM URINE Color-Straw Appear-Clear Sp ___
___ 03:12AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ OSH CTA head/neck ___ opinion (___)
IMPRESSION:
1. Segmental left vertebral artery occlusion of indeterminate
chronicity. No evidence of ischemia.
2. Somewhat small caliber attenuated left M2 inferior branch,
without evidence of focal occlusion.
3. No acute intracranial abnormality on noncontrast CT head.
___ MRI head w/o contrast
IMPRESSION:
1. No acute intracranial abnormality. Specifically, no large
territory infarction or hemorrhage.
2. Scattered foci of T2/high-signal intensity in the subcortical
and periventricular white matter are nonspecific and may reflect
changes due to chronic small vessel disease.
___ TTE
IMPRESSION: No structural source of thromboembolism identified
(underlying rhythm predisposes to thrombus formation). Preserved
left ventricular systolic function in the setting of
beat-to-beat variability due to arrhythmia. Mild to moderate
mitral and tricuspid regurgitation. Normal pulmonary pressure.
Very small pericardial effusion
Brief Hospital Course:
Ms. ___ is a ___ year old female with AFib on Eliquis, CHF,
HLD, HTN who presented w/ sudden onset dysarthria, abnormal arm
movements, and poor balance (walker at baseline). NIHSS 1 for
slurred speech at OSH. There, a CTA head and neck was completed,
and there was concern for left M2 branch attenuation concerning
for stenosis or occlusion, and she was subsequently transferred
for consideration of thrombectomy but NIHSS 0 on arrival so she
was not deemed a candidate. She was admitted to the Neurology
stroke service for further evaluation of possible TIA vs stroke.
No further symptoms noted during admission. MRI head w/o
contrast were without evidence of stroke. Reports recent
echocardiogram per outpatient PCP/cardiologist, reported as no
acute findings and so this was not repeated. She mentioned
concern about worsening memory, but able to perform ADLs w/
meals/cleaning provided by ALF (moved 10 months ago); it appears
there has been no acute change. She was taking apixiban 2.5mg
once daily (unclear why as this is a BID medication), and so her
dose was increased to 2.5mg BID (she was not a candidate for 5mg
BID due to her age and weight). She was started on atorvastatin
for her hyperlipidemia (LDL 126). EP cardiology was consulted
for frequent sinus pauses noted on telemetry that persisted
despite holding home atenolol, recommending discontinuing home
digoxin and close cardiology ___. Discharged to home w/
___ & ___ and close PCP ___.
#Transient slurred speech and instability, c/f TIA
- ___ consult - cleared for home with home services
- Started on atorvastatin for HLD and increased home apixaban to
therapeutic level
- ___ with stroke neurology after discharge
Her stroke risk factors include the following:
1) DM: A1c 5.5%
2) Likely chronic segmental left vertebral artery occlusion and
somewhat small caliber attenuated left M2 inferior branch
3) Hyperlipidemia: LDL 126
4) Obesity
5) No concern noted for sleep apnea - she does not carry the
diagnosis
An echocardiogram did not show a PFO on bubble study.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No
4. LDL documented? (X) Yes (LDL = 126) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (X) Yes - () No [if
LDL if LDL >70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL]
6. Smoking cessation counseling given? () Yes - (X) No [reason
(X) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No
9. Discharged on statin therapy? (X) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (X) Yes [Type: ()
Antiplatelet - (X) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (X) Yes - () No - () N/A
#Cognitive complaints
- B12 249 - one time IM supplementation, then start oral B12
supplementation
- Treponemal antibodies negative
- consider cognitive neurology referral as outpatient for memory
difficulties not appreciated on our examination
#Afib
#frequent sinus pauses
- stopped digoxin, will ___ closely w/ otpt cardiologist
(also PCP)
- increased to appropriate therapeutic dosing at Eliquis 2.5 mg
BID (reduced dose given age and weight <60 kg)
#HLD
- started atorvastatin
#HTN
- continue home antihypertensives
#elevated troponin (RESOLVED)
- Troponin elevated at OSH, negative on admission
#elevated TSH
- should recheck as otpt w/ PCP ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. Apixaban 2.5 mg PO DAILY
3. Losartan Potassium 50 mg PO DAILY
4. Digoxin 0.125 mg PO DAILY
5. LevoFLOXacin 500 mg PO Q24H
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth once daily at
bedtime Disp #*30 Tablet Refills:*5
2. Cyanocobalamin 500 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 500 mcg 1 tablet(s) by mouth
once daily Disp #*30 Tablet Refills:*5
3. Apixaban 2.5 mg PO BID
4. Atenolol 50 mg PO DAILY
5. LevoFLOXacin 500 mg PO Q24H
6. Losartan Potassium 50 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
transient dysarthria not secondary to TIA or stroke
Mild Vitamin B12 deficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of slurred speech due to
concern for an ACUTE ISCHEMIC STROKE, a condition where a blood
vessel providing oxygen and nutrients to the brain is blocked by
a clot. The brain is the part of your body that controls and
directs all the other parts of your body, so damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms. However, the MRI of your brain did not show
evidence of stroke or TIA. Your symptoms could have been related
to blood pressure, dehydration, alcohol use, or a combination of
these factors.
We are changing your medications as follows:
Increase apixaban to 2.5mg twice daily
Start Vitamin B12 daily supplement
Please take your other medications as prescribed.
Please follow up with your primary care physician as listed
below. You should also follow up with your cardiologist as you
were noted to have occasional pauses on cardiac monitoring.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, please pay attention to
the sudden onset and persistence of these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10001860-DS-12 | 10,001,860 | 21,441,082 | DS | 12 | 2188-03-30 00:00:00 | 2188-03-29 12:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins
Attending: ___.
Chief Complaint:
neck pain s/p fall
Major Surgical or Invasive Procedure:
None on this Admission
History of Present Illness:
___ male transferred from outside hospital for
evaluation of cervical ___ fracture. Today the patient was
attempting to use the bathroom and bent forward and fell hitting
the back of his head. There was no loss of consciousness. The
patient complains of headache and neck pain. The outside
hospital the patient had the head laceration stapled. A CT scan
did demonstrate the fracture. The patient denies any numbness,
tingling in his arms or legs. No weakness in his arms or legs.
Denies any bowel incontinence or bladder retention. No saddle
anesthesia. Denies any chest pain, shortness of breath or
abdominal pain.
Past Medical History:
PMH: a. fib, colon ca, htn, copd
MED: warfarin, allopurinol, asacol
ALL: pcn, sulfa
Social History:
___
Family History:
NC
Physical Exam:
C collar in place
UEC5C6C7C8T1
(lat arm) (thumb) (mid fing) (sm finger) (med arm)
Rintact intact intact intact intact
Lintact intact intact intact intact
T2-L1 (Trunk) intact
___ L2 L3 L4 L5S1S2
(Groin)(Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)
Rintactintactintactintact intactintact
Lintactintactintactintact intactintact
Motor:
UEDlt(C5)Bic(C6)WE(C6)Tri(C7)WF(C7)FF(C8)FinAbd(T1)
R 5 5 5 5 ___
L 5 5 5 5 ___
___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___
R ___ 5 5 5 5
L ___ 5 5 5 5
Babinski: negative
Clonus: not present
Brief Hospital Course:
Patient was admitted to the ___ ___ Surgery Service for
observation after a C2 fracture. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Diet was advanced as tolerated.
The patient was tolerated oral pain medication. Physical therapy
was consulted for mobilization OOB to ambulate. He remained
hypertensive from 160 - >180. Medicine consult appreciated -
felt this was long standing. recommended PRN antihypertensives
but cautioned against bringing pressure too low too quickly.
Hospital course was otherwise unremarkable. On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet.
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain, temp >100.5, headache
2. Allopurinol ___ mg PO DAILY
3. Mesalamine ___ 400 mg PO TID
4. Metoprolol Tartrate 25 mg PO BID
5. Omeprazole 20 mg PO DAILY
6. Warfarin 1 mg PO DAILY
7. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
8. Diazepam 2 mg PO Q12H:PRN spasms
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
C2 fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You have undergone the following operation: Anterior Cervical
Decompression and Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 5 lbs for
2 weeks. You will be more comfortable if you do not sit in a car
or chair for more than ~45 minutes without getting up and
walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can
tolerate.
oIsometric Extension Exercise in the collar: 2x/day x ___xercises as instructed.
-Swallowing: Difficulty swallowing is not uncommon after this
type of surgery. This should resolve over time. Please take
small bites and eat slowly. Removing the collar while eating
can be helpful however, please limit your movement of your
neck if you remove your collar while eating.
-Cervical Collar / Neck Brace: You need to wear the brace at
all times until your follow-up appointment which should be in 2
weeks. You may remove the collar to take a shower. Limit your
motion of your neck while the collar is off. Place the collar
back on your neck immediately after the shower.
-Wound Care: Monitor laceration at scalp for drainage/redness.
Your PCP may take these staples out.
-You should resume taking your normal home medications.
-You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on ___.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
-Follow up:
oPlease Call the office ___ and make an appointment
with Dr. ___ 2 weeks after the day of your operation if
this has not been done already.
oAt the 2-week visit we will check your incision, take baseline
x rays and answer any questions.
oWe will then see you at 6 weeks from the day of the operation.
At that time we will most likely obtain Flexion/Extension X-rays
and often able to place you in a soft collar which you will wean
out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.
Physical Therapy:
activity as tolerated
C-collar full time for 12 weeks
may use ambulatory assistive devices for safety
no bending twisting, or lifting >5lbs
Treatment Frequency:
monitor skin at chin and back of head for breakdown in C-collar
Followup Instructions:
___
|
10001884-DS-30 | 10,001,884 | 26,170,293 | DS | 30 | 2130-04-19 00:00:00 | 2130-04-22 13:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
IV Dye, Iodine Containing Contrast Media / Oxycodone /
cilostazol / Varenicline
Attending: ___.
Chief Complaint:
Nonexertional Chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ year old female with PMHx CAD, PVD and COPD
presenting with chest pain. She reports that she woke up at 3 am
with substernal pressure like pain which was associated with
shortness of breath. She rated the pain a ___ and reports that
it lasted for about 5 minutes and resolved spontaneously. She
had several more episodes of the same pain lasting about 5
minutes at a time throughout the morning but which were much
less severe. She hasn't had an episode of pain since 1 pm. She
denies palpitations, lightheadedness, dizziness, nausea,
vomiting, diaphoresis.
In the ED, initial vitals were: 98.0 50 156/73 20 99%
- Labs were significant for:
- Na 137 K 3.0 Cl 94 CO2 32 BUN 16 Cr 0.8
- Ca: 10.6 Mg: 1.9 P: 2.9
- WBC 5.9 Hgb 13.6 Hct 41.1 Plt 238
- ___: 10.7 PTT: 28.7 INR: 1.0
- Lactate:2.0
- Trop-T: <0.01
- Imaging revealed:
- CXR: No acute cardiopulmonary process
- The patient was given: PO Aspirin 243, IH Albuterol 0.083%
Neb, IH Ipratropium Bromide Neb, PO Potassium Chloride 40 mEq,
40 mEq Potassium Chloride / 1000 mL NS
- Vitals prior to transfer were: 98.1 84 163/118 17 100% RA
Upon arrival to the floor, patient denies chest pain, shortness
of breath, palpitations, lightheadedness, dizziness.
REVIEW OF SYSTEMS:
(+) Per HPI
Past Medical History:
ASTHMA/COPD/Tobacco use, Peripheral Arterial disease s/p recent
common iliac stenting, ATRIAL TACHYCARDIA, ATYPICAL CHEST PAIN,
CERVICAL RADICULITIS, CERVICAL SPONDYLOSIS, CORONARY ARTERY
DISEASE
HEADACHE, HIP REPLACEMENT, HYPERLIPIDEMIA, HYPERTENSION,
OSTEOARTHRITIS, HERPES ZOSTER, TOBACCO ABUSE, ATRIAL
FIBRILLATION
ANXIETY,GASTROINTESTINAL BLEEDING, OSTEOARTHRITIS,
ATHEROSCLEROTIC CARDIOVASCULAR DISEASE, PERIPHERAL VASCULAR
DISEASE, CATARACT SURGERY ___
Surgery:
BILATERAL COMMON ILIAC ARTERY STENTING ___
BUNIONECTOMY
HIP REPLACEMENT
PRIOR CESAREAN SECTION
GANGLION CYST
Social History:
___
Family History:
Mother: ___, HTN
Father: ___ CA
Brother: CA?
Brother: ___
Physical ___:
Admission PE:
Vitals: 98.4 159/66 91 16 93% RA Wt: 66.2
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur
heard best at RUSB, no rubs or gallops
Lungs: inspiratory and expiratory wheezes, no rales or rhonchi
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
Discharge PE:
Vitals: 98.5 ___ 20 ___ 98%RA
Weight: 64.5
Weight on admission: 66.2
General: NAD
HEENT: Sclera anicteric
Neck: JVP not elevated
CV: Regular rhythm with frequent skipped beats, normal S1 + S2,
___ systolic murmur heard best at RUSB, no rubs or gallops
Lungs: mild expiratory wheezes, diffuse mild rhonchi
(pre-nebulizer)
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, no edema
Pertinent Results:
Admission Labs:
___ 07:49PM ___ PTT-28.7 ___
___ 07:05PM LACTATE-2.0
___ 05:58PM GLUCOSE-103* UREA N-16 CREAT-0.8 SODIUM-137
POTASSIUM-3.0* CHLORIDE-94* TOTAL CO2-32 ANION GAP-14
___ 05:58PM estGFR-Using this
___ 05:58PM cTropnT-<0.01
___ 05:58PM CALCIUM-10.6* PHOSPHATE-2.9 MAGNESIUM-1.9
___ 05:58PM WBC-5.9 RBC-4.62 HGB-13.6 HCT-41.1 MCV-89
MCH-29.4 MCHC-33.1 RDW-14.7 RDWSD-47.1*
___ 05:58PM NEUTS-57.8 ___ MONOS-9.3 EOS-0.3*
BASOS-0.2 IM ___ AbsNeut-3.41 AbsLymp-1.88 AbsMono-0.55
AbsEos-0.02* AbsBaso-0.01
___ 05:58PM PLT COUNT-238
Discharge Labs:
___ 06:20AM BLOOD WBC-6.1 RBC-4.60 Hgb-13.4 Hct-41.2 MCV-90
MCH-29.1 MCHC-32.5 RDW-14.9 RDWSD-47.8* Plt ___
___ 06:20AM BLOOD Plt ___
___ 06:20AM BLOOD Glucose-97 UreaN-17 Creat-1.0 Na-134
K-4.2 Cl-96 HCO3-24 AnGap-18
___ 06:25AM BLOOD ALT-19 AST-22 LD(LDH)-260* AlkPhos-81
TotBili-0.4
___ 06:20AM BLOOD Calcium-9.7 Phos-3.7 Mg-1.9
Studies:
1. CXR ___: No acute cardiopulmonary process
2. ___: Exercise stress test
INTERPRETATION: This ___ year old woman with a history of PAD and
LBBB was referred to the lab from the ER following negative
serial
cardiac markers for evaluation of chest discomfort. The patient
was
referred for a dipyridamole stress test but due to her
theophylline
therapy we were not able to proceed. Due to her frequent atrial
ectopy we chose not to give her dobutamine but had her walk on
the treadmill instead. She exercised for 3 minutes of a modified
___ protocol and stopped due to leg claudication. The
estimated peak MET capacity was 2.5 which represents a poor
functional capacity for her age. No arm, neck, back or chest
discomfort was reported by the patient throughout the study. The
ST segments are uninterpretable for ischemia in the setting of
the baseline LBBB. The rhythm was sinus with frequent isolated
apbs, occasional atrial couplets and a 6 beat run of PSVT. Rare
isolated vpbs were also noted. Resting mild systolic
hypertension with a pprorpriate increase in BP with exercise and
recovery.
IMPRESSION: No anginal type symptoms or interpretable ST
segments at a high cardiac demand and poor functional capacity.
Nuclear report sent separately.
3. ___ CATH:
LMCA: short, no CAD. LAD: mild
focal origin disease (20%) and mild proximal disease (30%). LCX:
minimal luminal irregularities. RCA: 30%.
4. ECG ___: sinus rhythm with multiple PACs, left axis
deviation, old LBBB
5. ECG ___: Likely atrial tachycardia. Left bundle-branch
block. Compared to the previous tracing atrial tachycardia has
replaced sinus rhythm with premature atrial contractions. Left
bundle-branch block was previously noted.
6. ECHO ___: Conclusions
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). There
is considerable beat-to-beat variability of the left ventricular
ejection fraction due to an irregular rhythm/premature beats.
Tissue Doppler imaging suggests a normal left ventricular
filling pressure (PCWP<12mmHg). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets are
mildly thickened (?#). There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Physiologic
mitral regurgitation is seen (within normal limits). The left
ventricular inflow pattern suggests impaired relaxation. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
frequent atrial ectopy is seen; biventricular function appears
similar.
Micro: ___: Bcx pending
Brief Hospital Course:
Brief Hospital Course
===========================================================
___ PMH of CAD, PVD, and COPD presenting with recurrent
non-exertional substernal chest pain. The patient has a history
of mild CAD but labs were significant for negative troponins and
EKG was without ischemic changes. During her admission, she also
developed multiple episodes of atrial tachycardia (AFib vs.
Aflutter) and was started on Amiodarone for rate/rhythm control
and Rivaroxaban for anticoagulation, and kept on home dose of
Diltiazem also for rate control. She did not have any episodes
of chest pain during hospitalization, so was discharged once
atrial fibrillation/flutter was controlled. She will need to
follow up with her primary care doctor regarding vague chest
pain which led to admission.
Acute Issues:
========================================================
#Atrial Tachycardia: During admission pt had runs of wide
complex tachyarrythmia, thought likely supraventricular in
origin: rapid Atrial Fibrillation/ Flutter vs. atrial
tachycardia, with abberancy (complexes with similar morphology
to native LBBB). She was treated with Diltiazem and Amiodarone
and had fewer episodes of tachycardia. EP team evaluated patient
and recommended anticoagulation and outpatient follow up to
consider EP study and possible ablation of Atrial Flutter.
Patient was discharged with ___ of Hearts monitor, Amiodarone
200mg twice daily x 1 week followed by 200 mg daily thereafter.
Diltiazem continued at home dose. Rivaroxaban added for
anticoagulation. As per outpatient cardiologist (Dr. ___,
plavix was discontinued in light of addition of Rivaroxaban and
interest in avoiding triple therapy in this patient. Pt was
given follow up appointments with Drs. ___. She was
scheduled to see Dr. ___ EP evaluation in 2 months.
#Chest pain: Pt presented with substernal chest pain that
occurred at rest and was ruled out for MI with no troponin
elevation or significant new ECG changes. Likely her chest pain
was related to periods of tachycardia, although while in the
hospital the runs of atrial tachycardia did not reproduce chest
pain. She did not have any episodes of chest pain during
hospitalization, so was discharged once atrial
fibrillation/flutter was controlled. She will need to follow up
with her primary care doctor regarding vague chest pain which
led to admission.
#Dry eyes: pt had erythema and pain of R eye, found to have dry
eyes per optholmology. Sent out with Artificial tears and
erythromycin eye drops. Patient had follow up appointment
already scheduled with optholmology and was instructed to attend
appointment.
Chronic Issues:
=============================================================
# COPD Pt appeared to be at baseline respiratory status. She
was sent home with her home albuterol neb, albuterol inhaler,
Fluticasone nasal spray, fluticasone-salmeterol diskus,
tiotropium bromide nebs, and theophylline
# PAD:
As above, we stopped Clopidogrel as patient is now on
Rivaroxaban and wanted to avoid triple therapy as per her
cardiologist Dr. ___.
Transitional Issues:
==============================================================
1. Patient was discharged on Amiodarone 200 mg po twice daily
for one week until ___ and then 200mg po daily thereafter
until her EP appointment with Dr. ___ in approximately 2 months.
2. Pt was discharged on Rivaroxaban 20 mg qpm with dinner
3. Pt discharged with outpatient ___ of Hearts monitor with
results to be interpreted by Cardiologist.
4. She presented with chest pain but did not have elevated
biomarkers or EKG changes concerning for myocardial damage.
Moreover, pt remained asymptomatic during periods of
supraventricular tachycardia while she was hospitalized. Patient
may benefit from outpatient stress test if such symptoms return.
5. On day of discharge, pt had significant R eye pain and
redness, was evaluated by Optholmology, who felt that it was
just dry eyes, treated with erythromycin drops and artifiical
tears. Patient already has appt w/ Opthamology in 5 days which
she will need to attend.
Full Code
Contact: CONTACT: ___ (husband) ___ ___
(daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325 mg PO Q4H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Clopidogrel 75 mg PO DAILY
6. Diltiazem Extended-Release 180 mg PO DAILY
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN nasal
congestion
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Hydrochlorothiazide 50 mg PO DAILY
10. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
11. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS
12. Lorazepam 0.5 mg PO QHS:PRN insomnia
13. Multivitamins W/minerals 1 TAB PO DAILY
14. Ranitidine 150 mg PO BID
15. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
16. Theophylline ER 300 mg PO BID
17. Tiotropium Bromide 1 CAP IH DAILY
18. Guaifenesin-CODEINE Phosphate 5 mL PO Q6H:PRN cough
19. cod liver oil 1,250-135 unit oral BID
20. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3)
315/200 mg oral daily
Discharge Medications:
1. Amiodarone 200 mg PO BID
RX *amiodarone 200 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*1
2. Rivaroxaban 20 mg PO DINNER
RX *rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth qpm Disp
#*30 Tablet Refills:*1
3. Acetaminophen 325 mg PO Q4H:PRN pain
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 10 mg PO QPM
7. Diltiazem Extended-Release 180 mg PO DAILY
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN nasal
congestion
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
10. Guaifenesin-CODEINE Phosphate 5 mL PO Q6H:PRN cough
11. Hydrochlorothiazide 50 mg PO DAILY
12. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
13. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS
14. Lorazepam 0.5 mg PO QHS:PRN insomnia
15. Multivitamins W/minerals 1 TAB PO DAILY
16. Ranitidine 150 mg PO BID
17. Theophylline ER 300 mg PO BID
18. Tiotropium Bromide 1 CAP IH DAILY
19. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
20. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN eye
irritation
RX *dextran 70-hypromellose [Artificial Tears] 1 drop OPTH
QID:prn Refills:*0
RX *dextran 70-hypromellose [Artificial Tears (PF)] ___ drops
eye as needed Disp #*1 Package Refills:*1
21. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE TID
RX *erythromycin 5 mg/gram (0.5 %) 0.5 (One half) inch OPTH
TID:prn Refills:*0
22. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3)
315/200 mg oral daily
23. cod liver oil 1,250-135 unit oral BID
Discharge Disposition:
Home
Discharge Diagnosis:
Rapid Atrial Fibrillation/Flutter
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ due to concerning chest pain symptoms
which we think are due to infrequent bursts of a rapid heart
rate. Since the rapid rate makes you at increased risk for
stroke, you were started on a blood thinning medication called
Rivaroxaban which you will need to take every day. Our
specialized cardiologists who deal specifically with the
electrical rhythm of the heart evaluated you and felt that you
would benefit from a medication called amiodarone which was also
started. You will need to follow up with them in their clinic
regarding this abnormal rhythm. In the meantime, you were
outfitted with a Holter monitor to record your heart rate at
home. It is very important that you follow up with Dr. ___
your cardiologist.
We wish you all the best,
Sincerely,
Your care team at ___
Followup Instructions:
___
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